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Clinical Guidelines November 1, 2012 Montgomery County Hospital District Emergency Medical Services

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Montgomery County Hospital District Emergency Medical Services Clinical Guidelines November 1, 2012 This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page iii TOC INTRO-1 INTRO-2 INTRO-3 INTRO-4 INTRO-5 CG 01 CG 02 CG 03 CG 04 CG 05 CG 06 CG 07 CG 08 CG 09 CG 10 CG 11 CG 12 CG 13 CG 14 CG 15 CG 16 CG 17 CG 18 CG 19 CG 20 CG 21 CG 22 CG 23 CG 24 CG 25 CG 26 CG 27 CG 28 CG 29 CG 30 CG 31 CG 32 CG 33 CG 34 CG 35 CG 36 CG 37 CG 38 CG 39 CG 40 CG 41 INTRODUCTION Table of Contents Medical Director Statement Standard of Care Statement Clinical Guidelines and Protocols Definitions CLINICAL GUIDELINES General Therapies Diagnostic Tools and Procedures Medication Standards Protocol Deviations Supervisor Notification Patient Status Radio Report and Consult Guidelines Communications Failure Chain of Command Non-MCHD Personnel on Scene Medical Authorization Levels PIII and Squad Authorization Paramedic I Promotional Requirements Paramedic II Promotional Requirements Paramedic III Promotional Requirements Paramedic IV Promotional Requirements Transfer Care Unit/Special Event Authorization First Responder Scope of Practice Encountering Emergencies Potentially Violent Scenes and Staging Coordination with Law Enforcement Requests for Assistance Transporting Patient Valuables Organ Donor Procurement – LifeGift Patient Consent Patient Refusal Oxygen Third Riders Non-Emergency Assist Calls Confidentiality OOH DNR and Death on Scene Destination Determination Facility Diversion Air Medical Utilization Controlled Substances Medication Storage EMD Determinants Version 11 File Transfer of Patient Care Records Allied Health Care Providers Primary Survey / CABC’S Focused and Detailed Exam Revision 03/28/2011 Page i xii xiii xiv xvii Rev. Date 03/01/2010 08/06/2012 11/01/2005 11/01/2005 03/28/2011 02/01/2006 02/28/2011 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 01/26/2009 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 06/21/2012 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page iv TOC CG 42 CG 43 CG 44 CG 45 CG 46 CG 47 CG 48 CG 49 Documentation Standards New Employee Orientation Program Card Courses and Educational Opportunities Recertification and Upgrade in Certification Continuous Quality Improvement Handling Child and Elderly Abuse and Neglect Care and Transportation of Minors Department of State Health Minimum Inventory List CLINICAL GUIDELINES 07/23/2010 03/28/2011 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 08/06/2012 ADULT PROTOCOLS – BEHAVIORAL AB 01 AB 02 AB 03 AB 04 Behavioral Assessment Abuse / Neglect Aggressive / Violent Behavior Anxiety / Emotional Distress 11/01/2005 11/01/2005 07/26/2010 11/01/2005 ADULT PROTOCOLS – CARDIAC AC 01 AC 02 AC 03 AC 04 AC 05 AC 06 AC 07-A AC 07-B AC 08 AC 09 AC 10 AC 11 AC 12 AC 13-A AC 13-B Cardiac Assessment Acute Coronary Syndrome / AMI Asystole Bradycardia CHF / Pulmonary Edema Hypothermic Induced Arrest Narrow Complex Tachycardia – Stable Narrow Complex Tachycardia – Unstable Non-Traumatic Chest Pain Post Resuscitation Mgmt Pulseless Electrical Activity Ventricular Ectopy Ventricular Fibrillation / Pulseless Vent. Tachycardia Wide Complex Tachycardia – Stable Wide Complex Tachycardia – Unstable 11/01/2005 08/01/2007 11/21/2011 11/01/2005 03/28/2011 02/28/2011 06/21/2012 02/28/2011 08/01/2007 01/26/2009 11/21/2011 11/01/2005 06/21/2012 11/01/2005 02/28/2011 ADULT PROTOCOLS – ENVIRONMENTAL AE 01 AE 02 AE 03 AE 04 AE 05 AE 06 Environmental Assessment Cold Related Emergency Heat Related Emergency Insect / Animal / Snake Bite Near Drowning Toxicological / HAZMAT 11/01/2005 11/01/2005 02/28/2011 08/01/2007 08/01/2007 11/01/2005 ADULT PROTOCOLS – MEDICAL AM 01 AM 02 AM 03 AM 04 AM 05-A AM 05-B AM 06 AM 07 AM 08 Medical Assessment Allergic Reaction AMS / Unconscious Cerebrovascular Accident Diabetic – Hyperglycemia Diabetic – Hypoglycemia Dystonic Reaction Fever Hypertensive Crisis Revision 03/28/2011 11/01/2005 07/26/2010 02/28/2011 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page v TOC AM 09 Malnutrition / Dehydration AM 10 Non-Traumatic Abdominal Pain AM 11 Non-Traumatic Hemorrhage AM 12 Non-Traumatic Shock / Hypotension AM 13 Overdose / Poisoning AM 14 Seizures AM 15 Syncope ADULT PROTOCOLS – RESPIRATORY AR 01 Respiratory Assessment AR 02 Airway Obstruction AR 03 Bronchospasm AR 04 COPD AR 05 Hyperventilation AR 06 Pneumonia AR 07 Pulmonary Embolism AR 08 Respiratory Distress ADULT PROTOCOLS – OB OB 01 OB Assessment OB 02 Abdominal Pain – Female OB 03 Pre-Eclampsia / Toxemia OB 04 Eclampsia / Toxemia OB 05 Labor OB 06 Childbirth / Imminent Delivery OB 07 Neonate Care OB 08 Limb Presentation OB 09 Prolapsed Umbilical Cord OB 10 Spontaneous Abortion OB 11 Vaginal Bleeding ADULT PROTOCOLS – TRAUMA AT 01 Trauma Assessment AT 02 Amputation AT 03 Burns AT 04 Taser AT 05 Evisceration AT 06 Eye Injury AT 07 Head Trauma AT 08 Multi-System Trauma AT 09 Musculoskeletal – Soft Tissue Injury AT 10 Penetrating Injury AT 11 Sexual Assault AT 12 Spinal Trauma AT 13 Traumatic Arrest PEDIATRIC PROTOCOLS – BEHAVIORAL PB 01 Behavioral Assessment PB 02 Abuse / Neglect PB 03 Aggressive / Violent Behavior PB 04 Anxiety / Emotional Distress Revision 03/28/2011 11/01/2005 08/01/2007 11/01/2005 11/01/2005 02/28/2011 08/01/2007 11/01/2005 11/01/2005 08/01/2007 02/28/2011 05/21/2007 11/01/2005 08/01/2007 06/26/2006 11/01/2005 11/01/2005 08/01/2007 02/28/2011 03/02/2011 11/01/2005 11/01/2005 06/21/2012 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 08/01/2007 08/01/2007 11/01/2005 08/01/2007 08/01/2007 11/01/2005 11/01/2005 08/01/2007 08/01/2007 11/01/2005 11/01/2005 06/21/2012 11/01/2005 11/01/2005 11/01/2005 11/01/2005 Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page vi TOC PEDIATRIC PROTOCOLS – CARDIAC PC 01 Cardiac Assessment PC 02 Asystole PC 03 Bradycardia PC 04 Hypothermia / Hypothermic Arrest PC 05 Post Resuscitation Management PC 06-A Narrow Complex Tachycardia – Stable PC 06-B Narrow Complex Tachycardia – Unstable PC 07 Pulseless Electrical Activity PC 08 Non-traumatic Chest Pain PC 09 Ventricular Ectopy PC 10 Ventricular Fibrillation / Pulseless Vent. Tachycardia PC 11-A Wide Complex Tachycardia - Stable PC 11-B Wide Complex Tachycardia - Unstable PEDIATRIC PROTOCOLS – ENVIRONMENTAL PE 01 Environmental Assessment PE 02 Cold Related Emergency PE 03 Heat Related Emergency PE 04 Insect / Animal / Snake Bite PE 05 Near Drowning PE 06 Toxicological / HAZMAT PEDIATRIC PROTOCOLS – MEDICAL PM 01 Medical Assessment PM 02 Allergic Reaction PM 03 AMS / Unconscious PM 04 Dehydration PM 05 - A Diabetic - Hyperglycemia PM 05 - B Diabetic - Hypoglycemia PM 06 Dystonic Reaction PM 07 Fever PM 08 Non-traumatic Abdominal Pain PM 09 Non-traumatic Hemorrhage PM 10 Non-traumatic Shock / Hypotension PM 11 Overdose / Poisoning PM 12 Seizures PM 13 Syncope PEDIATRIC PROTOCOLS – RESPIRATORY PR 01 Respiratory Assessment PR 02 Airway Obstruction PR 03 Bronchospasm PR 04 Croup PR 05 Epiglottis PR 06 Pneumonia PR 07 Respiratory Distress PR 08 Respiratory Failure / Shock PEDIATRIC PROTOCOLS – TRAUMA PT 01 Trauma Assessment Revision 03/28/2011 11/01/2005 11/08/2006 11/01/2005 02/28/2011 08/01/2007 11/01/2005 11/01/2005 08/01/2007 08/01/2007 11/01/2005 02/28/2011 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 08/01/2007 11/01/2005 11/01/2005 11/01/2005 03/28/2011 08/01/2007 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 08/01/2007 08/01/2007 11/01/2005 11/01/2005 11/01/2005 03/28/2011 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page vii TOC PT 02 PT 03 PT 04 PT 05 PT 06 PT 07 PT 08 PT 09 PT 10 PT 11 PT 12 PROC 01 PROC 02 PROC 03 PROC 04 PROC 05 PROC 06 PROC 07 PROC 08 PROC 09 PROC 10 PROC 11 PROC 12 PROC 13 PROC 14 PROC 15 PROC 16 PROC 17 PROC 18 PROC 19 PROC 20 PROC 21 PROC 22 PROC 23 PROC 24 PROC 25 PROC 26 PROC 27 PROC 28 PROC 29 PROC 30 Amputation Burns Evisceration Eye Injury Head Trauma Multi-system Trauma Musculoskeletal – Soft Tissue Injury Penetrating Injury Sexual Assault Spinal Trauma Traumatic Arrest PROCEDURES 12-Lead ECG Monitoring Adenosine Administration Basic Airway Management Blood Draw Request by Texas J.P. Blood Glucose Analysis Chest Decompression Combitube Continuous Positive Airway Pressure Ventilation (CPAP) C-Spine Clearance Procedure End Tidal CO2 Detection Intubation External Pacing Helmet Removal Medication Administration Nasogastric Tube Insertion & Lavage Nitrous Oxide Administration Orthostatic Vital Signs Pain Management ParaPac Ventilator Patient Safety Restraint Pericardiocentesis Pharmacological Assisted Intubation - RSI Positive End Expiratory Pressure Pulse Oximetry Monitoring Spinal Motion Restriction Surgical Airway Termination of Medical Resuscitation Tourniquet Use Vagal Maneuvers Vascular Access 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/25/2008 11/01/2005 03/28/2011 11/01/2005 03/28/2011 11/01/2005 06/21/2012 11/01/2005 08/01/2007 11/01/2005 11/01/2005 07/26/2010 02/28/2011 11/01/2005 03/28/2011 11/01/2005 11/01/2005 11/01/2005 03/28/2011 11/01/2005 07/26/2010 06/21/2012 06/21/2012 11/01/2005 11/01/2005 11/01/2005 11/01/2005 07/26/2010 06/21/2012 11/01/2005 03/28/2011 MEDICINE REFERENCE Acetaminophen Activated Charcoal Adenosine Aspirin Revision 03/28/2011 11/01/2005 11/01/2005 02/01/2006 11/01/2005 Montgomery County Hospital District-EMS Clinical Guidelines – Introduction SRS 01 TABLE OF CONTENTS INTRO 01 Atropine Sulfate Diphenhydramine Diltiazem Amiodarone Calcium Gluconate Decadron Dextrose (25%-50%) Dopamine HCL Epinephrine HCL Etomidate Fentanyl Glucagon Ibuprofen Labetalol Ketamine Lasix Lidocaine HCL Magnesium Sulfate Metoprolol Morphine Sulfate Naloxone Nitroglycerin Nitrous Oxide Normal Saline Oxygen Promethazine Pitocin Retavase (if available) Sodium Bicarbonate Methylprednisolone Stadol Succinylcholine Chloride Tetracaine Ophthalmic Solution Thiamine Diazepam Vasopressin Vecuronium Midazolam Xopenex Ondansetron SPECIAL RESPONSE SCENARIOS Rehabilitation of Responders at Emergencies Page viii TOC 03/28/2011 11/01/2005 05/21/2007 02/01/2006 11/01/2005 11/01/2005 11/01/2005 11/01/2005 03/28/2011 11/01/2005 06/10/2009 02/01/2006 11/01/2005 05/21/2007 02/28/2011 03/28/2011 11/01/2005 11/01/2005 07/26/2010 03/28/2011 02/28/2011 02/01/2006 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 01/11/2010 11/01/2005 11/01/2005 03/28/2011 11/01/2005 11/01/2005 11/01/2005 11/01/2005 03/01/2010 11/01/2005 08/01/2007 11/01/2005 01/26/2009 06/21/2012 APPENDIX APP 01 APP 02 APP 03 APP 04 12-Lead Guide Ambulance Acceptable Abbreviations APGAR Capnography Revision 03/28/2011 11/01/2005 11/01/2005 11/01/2005 11/01/2005 Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page ix TOC APP 05 APP 06 APP 07 APP 08 APP 09 APP 10 APP 11 APP 12 APP 13 APP 14 APP 15 APP 16 APP 17 APP 18 APP 19 APP 20 APP 21 Date 06/26/2006 11/08/2006 11/08/2006 11/08/2006 11/08/2006 11/08/2006 11/08/2006 11/08/2006 05/21/2007 05/21/2007 05/21/2007 05/21/2007 05/21/2007 05/21/2007 05/21/2007 05/21/2007 Glascow Coma Scale – Adult and Pediatric Infusion Calculations Mallampati Signs MCHD Stroke Scale Oxygen Duration Pain Assessment Rule of Nines Subject in Custody Risk Assessment Scale Trauma Scores EZ IO Humeral Placement Provisional Procedure Point of Care Cardiac Marker Provisional Procedure Impedance Threshold Device (ResQPOD®) Intranasal Medication Administration Induced Hypothermia Implantable Venous Access Device (iVAD) Controlled Substances PETC Inclusion/Exclusion Criteria Protocol Update Log Protocol Changed Comment AR07 – Pulm. Embolism Changed Physical Findings APP 17 – ResQPOD Added Procedure PROC 30 & 31 Added ResQPOD PC 02,04,05,07,10 Added ResQPOD AC 03, 06, 09, 10, 12 Added ResQPOD AT 09 – Musculoskeletal Added Compartment Syndrome AT 13 – Traumatic Arrest Added ResQPOD PT 12 – Traumatic Arrest Added ResQPOD AC 02 – ACS Add Metoprolol/Removed Labetalol AC 07A & AC 07B – Narrow Updated Diltiazem dosage Complex AR 03, 04, 06 Added CPAP APP 18 – Metoprolol Medication Added CG 49 – Inventory Min. Updated MED 07 – Diltiazem Updated Dosage MED 18 – Labetalol Updated Indications PROC 09 – CPAP Updated Indications Revision 03/28/2011 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 11/01/2005 03/28/2011 02/01/2006 11/25/2008 08/01/2007 03/01/2010 03/28/2011 06/21/2012 06/21/2012 Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page x TOC 08/01/2007 08/01/2007 08/01/2007 08/01/2007 PROC 09 & 20 AC 05, AE 05,AR 03,04,06 AC 02, 08; AE 04; AM 10; OB 02; AT 02, 03, 05, 06, 09, 10; PC 08; PE 04 APP 19 AC 03,10,12; AM 03,13,14 OB 04,07; PC 05, 07,10; PM 03,11,12 MED 15,23,40 08/01/2007 02/14/2008 02/14/2008 02/14/2008 02/14/2008 09/08/2008 11/25/08 11/25/08 01/21/09 01/26/2009 Inventory Minimums INTRO 02 APP 20 and 21 AC 09 OB 06 & OB 10 APP 22 iVAD AT 13, PT 12, & APP 17 APP 23 Controlled Substances PROC 20 Pain Management MED REF 42 01/26/2009 01/26/2009 06/10/2009 AC 09 CG 14 CG 49 06/10/2009 MED REF 15 06/10/2009 1/11/2010 1/11/2010 3/1/2010 PROC 25 MED REF 30 CG 32 AC 03, AC10, AC 12 08/01/2007 08/01/2007 08/01/2007 3/1/2010 APP 20 3/1/2010 3/1/2010 6/29/2010 6/29/2010 7/26/2010 7/23/2010 MED REF 38 Minimums List CG 49 Minimums List CG 49 AM 05-B CG 32 CG 42 Revision 03/28/2011 Updated Procedure for CPAP and Pain Mgmt CPAP settings changes Pain Management moved above Consult Intranasal Medication Administration added Naloxone IN Administration Naloxone IN Administration IN Route Added for Fentanyl, Naloxone, Midazolam Updated New Signature page with proper dates Added Zoll 12 Lead and Hypothermia Procedure Added Consult for shivering control Removed Pitocin Added New Procedure Deleted references to ResQPod for trauma Updated CG 35 Updated Treatment Options Added Ondansetron to AC 02, AC 08, AE 03, AM 04, AM 05-A, AM 08, AM 09, AM 10, OB 02, OB 03, OB 04, OB 05, OB 08, AT 02, AT 03, AT 12, PC 08, PE 03, PE 04, PM 04, PM 05-A, PM 08, Patient 02, Patient 05, Patient 08. Clarification when to give Amiodarone. Added Resume’ to items required. Minimum List Title changed to: Department of State Health Minimum Inventory List Amended Fentanyl adult dosages to agree with Pain Management guidelines. Nerve Stimulator may be used if available noted. Retavase may be available Destination Determination Updated Change Vasopressin dosage, Revise Epinephrine dosing, addition of Induced Hypothermia procedure, minimum 20-minute CPR. Induce hypothermia in CPR greater than 5 minutes, Midazolam/Vecuronium only to control shivering, no consult for Midazolam Vasopressin - added repeat q5 Vasopressin vial concentration change Oral Glucose vendor packaging change to 31g Oral Glucose vendor packaging change to 31g Added St. Luke’s-Lakeside, chart updated Assist call procedure updated Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page xi TOC 7/26/2010 7/26/2010 7/26/2010 7/26/2010 AB 03 AM 02 AR 03 PROC 12 7/26/2010 7/26/2010 7/26/2010 7/26/2010 7/26/2010 PROC 15 PROC 22 PROC 23 PROC 25 PROC 30 7/26/2010 PROC 31 7/26/2010 7/26/2010 7/26/2010 12/9/2010 MED REF MED REF MED REF AR 03 12/9/2010 12/9/2010 02/28/2011 02/28/2011 02/28/2011 02/28/2011 02/28/2011 PROC 22 CG 32 AC 10 AC 06 AC 07, AC 13 AC 12 AE 03 02/28/2011 02/28/2011 02/28/2011 AM 03, AM 13 APP 14 , APP 21 APP 22 02/28/2011 02/28/2011 02/28/2011 02/28/2011 02/28/2011 AR 03 CG 02 CG 32 OB 03, OB 04 02/28/2011 02/28/2011 02/28/2011 PC 04, PC 10 PROC 13 PROC 20 02/28/2011 PROC 25 02/28/2011 02/28/2011 02/28/2011 03/02/2011 Med Ref - Ketamine Med Ref - Naloxone Med Ref – Atropine Sulfate OB 04 Revision Date 11/01/2011 Ketamine added to treatment Epinephrine before Xopenex in moderate reaction CPAP setting start at 3 Combined Intubation and ET Introducer “Bougie first method” Combined with PROC 12 Added step to continue restraint with AB 03 Combined with PROC 22 Ketamine added to treatment Termination criteria updated, extended medical authorization mentioned Procedure updates, extended medical authorization mentioned Numbers removed, re-alphabetized Ketamine-added to MED REF list Metoprolol-Moved from APP 18 to MED REF list Changed Epi from SQ to IM, added Ketamine for post intubation sedation Added ETCO2 monitoring requirement Destination Grid updated Naloxone dose change and remove Atropine Defibrillation change to 150j Cardioversion Energy Settings Change Defibrillation Energy and Naloxone Dose Added cooled saline as secondary intervention and updated physical findings Updated Naloxone Dosing Deleted Remove consult requirement for advanced authorization Updated Ketamine Dosing Updated temperature monitoring Added to Grid, St. Luke’s Hospital at the Vintage Changed Magnesium Dose from 1 to 2 g. Updated Historical Findings to include post partum patients Updated Defib Ref (removed stacked shocks) Updated to correspond to Philips MRx Updated reference to Diazepam or Midazolam for muscle spasms after primary pain medications (requires consult). Removed reference to morphine. Updated Ketamine dose and clarified usage in relation to Vecuronium and Midazolam Updated dose to 1-2 mg / kg IV or 2-4 mg / kg IM Change from 2 - 8mg to 0.4 to 2 mg Asystole removed Changed Magnesium Dose from 1 to 2 g Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page xii TOC 03/09/2011 03/28/2011 03/28/2011 03/28/2011 03/28/2011 03/28/2011 AC 03 CG 32 CG 43 CG 49 AC 05 PM 02 03/28/2011 PR 03 03/28/2011 03/28/2011 03/28/2011 03/28/2011 03/28/2011 03/28/2011 PROC 02 PROC 05 PROC 16 PROC 20 PROC 24 PROC 33 03/28/2011 03/28/2011 Med Ref – Atropine Med Ref – Epinephrine 03/28/2011 03/28/2011 03/28/2011 03/28/2011 03/28/2011 03/28/2011 5/27/2011 Med Ref – Lasix Med Ref – Morphine Med Ref– Stadol APP 15 APP 22 INTRO 05 CG 32 6/21/2012 CG 20 6/21/2012 6/21/2012 6/21/2012 CG 32 APP 21 CG 49 6/21/2012 6/21/2012 6/21/2012 6/21/2012 AC 07-A AC 12 AT 13 OB 07 6/21/2012 6/21/2012 PROC 04 PROC 07 6/21/2012 PROC 24 6/21/2012 PROC 25 Revision Date 11/01/2011 Naloxone dose change Level 1 & Level 2 activation added. Updated FTO Program and OMD updates. Remove Lasix and Iodine Remove Lasix and Morphine Update Epi dosing from SQ to IM, Methylprednisolone Chart updated Update Epi dosing from SQ to IM, Methylprednisolone Chart added Replace Iodine with Chlorohexidine Cleansing site with Chlorohexidine, #13 deleted Remove Morphine Remove Morphine Replace Iodine with Chlorohexidine Replace Iodine with Chlorohexidine , Lidocaine for Pedi IO Dosing to prevent hypersalivation added. Update Allergic Reaction & Bronchospasm from SQ to IM, Adult and Pedi Deleted Deleted Deleted Replace Iodine with Chlorohexidine Replace Iodine with Chlorohexidine Remove MONA/Morphine Removed St. Luke’s Freestanding ER from Approved destination list. Revised “Potentially Violent Scenes and Staging” in accordance with 10/12/10 Ops Bulletin Changed ICES to PETC NEW – PETC Inclusion/Exclusion Criteria Updated Minimum Inventory List; Deleted Medications: Lasix, Morphine, Pitocin, Stadol Added “consider fluid bolus if BP is <90 systolic Corrected 2nd dose of Amiodarone Added “Do Not Attempt Resuscitation” Guidelines Under Critical Points added bullet point “For Neonate transfer refer to CG 39 “Allied Health Care Providers” Deleted “Baxter Pump/Administration of IV Fluid” Revised “Chest Decompression”; Equipment and Procedure Changes Now PROC 21; Revised “Pericardiocentesis”. Complete procedure revision; Incorporate 3-holepunch procedure/equipment Revised PROC 22 “Pharmacological Assisted Montgomery County Hospital District-EMS Clinical Guidelines – Introduction 6/21/2012 6/21/2012 PROC 28 PROC 31 6/21/2012 Re-numbered all PROC pages 6/21/2012 SRS 01 6/21/2012 6/21/2012 6/21/2012 APP 20 (formerly APP 23) APP 24 Re-numbered all APP pages Revision Date 11/01/2011 TABLE OF CONTENTS INTRO 01 Page xiii TOC Intubation - RSI NEW “Tourniquet Use” Deleted “Termination of Trauma Resuscitation” incorporated into AT 13. PROC 05 to PROC 04 PROC 06 to PROC 05 PROC 07 to PROC 06 PROC 08 to PROC 07 PROC 09 to PROC 08 PROC 10 to PROC 09 PROC 11 to PROC 10 PROC 12 to PROC 11 PROC 13 to PROC 12 PROC 14 to PROC 13 PROC 15 combined with PROC 12 (7/26/10) PROC 16 to PROC 14 PROC 17 to PROC 15 PROC 18 to PROC 16 PROC 19 to PROC 17 PROC 20 to PROC 18 PROC 21 to PROC 19 PROC 22 to PROC 20 PROC 23 combined with PROC 22 (7/26/10) PROC 24 to PROC 21 PROC 25 to PROC 22 PROC 26 to PROC 23 PROC 27 to PROC 24 PROC 28 to PROC 25 PROC 29 to PROC 26 PROC 30 to PROC 27 PROC 31 (Termination of Trauma Resuscitation) DELETED; incorporated with AT 13 NEW PROC 28 (Tourniquet Use) PROC 32 to PROC 29 PROC 33 to PROC 30 NEW “Rehabilitation of Responders at Emergencies” Revised “Controlled Substance” NEW – PETC Inclusion/Exclusion Criteria APP 14 – Zoll M Series Quick Reference (DELETED 02/28/11) APP 15 to APP 14 APP 16 to APP 15 APP 17 to APP 16 APP 18 (Metoprolol - Moved to Med Ref list 07/26/2010) APP 19 to APP 17 APP 20 to APP 18 APP 21 (Zoll Digital 12-Lead Transmission – Deleted 02/28/11) APP 22 to APP 19 Montgomery County Hospital District-EMS Clinical Guidelines – Introduction TABLE OF CONTENTS INTRO 01 Page xiv TOC APP 23 to APP 20 08/06/2012 08/06/2012 10/01/2012 Intro – Medical Director Stmt CG 49 All 10/01/2012 10/01/2012 Revision Date 11/01/2011 Change effective 08/06/2012 Changed Medical Director Signature/Date Replaced Versed with Midazolam Replaced Valium with Diazepam Replaced Zofran with Ondansetron Replaced Cardizem with Diltiazem Replaced Narcan with Naloxone Replaced Cordarone with Amiodarone Added Ondansetron IV Added Morphine IV Added NTG Paste Added Hydroxocobalamin Revised RSI Procedure. Renamed to RSI Added Hydroxocobalamin Administration Procedure Changed Effective Date 11/1/2012 Montgomery County Hospital District-EMS Clinical Guidelines – Introduction Revision Date 08/06/2012 MEDICAL DIRECTOR STATEMENT INTRO 02 Page xv TOC xv Montgomery County Hospital District-EMS Clinical Guidelines – Introduction STANDARD OF CARE STATEMENT INTRO 03 Page xvi TOC The public expects a certain level of knowledge and skill from MCHD personnel. Clinical competence and high standards are vital components in providing quality pre-hospital emergency medical care to the customers who rely on our service. The general treatment protocols are in this section of the manual. They represent the level of patient care that is to be provided whenever there is a request for service. The specific orders for each patient are found in the Clinical Guidelines (SDO’s). The general guidelines discuss treatment and patient philosophies. MCHD embraces as fundamental components of its standard of care the following concepts: • The emergent patient benefits from early medical interventions, especially the early and aggressive application of airway establishment and maintenance, early administration of oxygen, early protection of the cervical spine and early initiation of definitive therapies. • The patient defines the emergency. As EMS personnel, you are often called upon to assist with social or psychological problems therefore you should respond as professionally and thoroughly to these as you do for medical or trauma patients. When possible and appropriate, pre-hospital personnel should follow the desires and wishes of patients and their families. MCHD EMS personnel should be expected to conduct themselves in a professional manner and treat all patients with dignity and respect. Our patients’ medical information should be treated in a confidential manner • Your role as EMS personnel is to truly act as the eyes, ears and hands of the physician. To successfully do so requires that we educate ourselves beyond first aid procedures and dedicate ourselves to becoming an integral part of the total health care team. MCHD EMS personnel are expected to use their knowledge, training, judgment and expertise in pre-hospital care when caring for patients under these standing orders. MCHD EMS personnel’s first priority in the field should be safety for themselves, patients and the public. This includes the use of appropriate personal protective equipment. Patients with the most severe, or life threatening, injuries or illness should be treated first, except in the event of a multiple patient scene/mass casualty incident where the field resources are overwhelmed. Every patient contact begins with the ABCs and/or CPR as appropriate. Once adequate life support is established EMS personnel should perform the primary and secondary survey to determine and then treat illness or injury. Standard of Care is dynamic, changing and improving on a regular basis. It is not possible to produce a written document: that addresses every clinical situation or that is perpetually up to date. It is therefore necessary for MCHD EMS personnel to continuously update their own knowledge and, at times, to rely upon clinical judgment not discussed in written policy. Compassion for the patient tempered by intellectual honesty should direct MCHD EMS personnel when applying these protocols to patient care. Revision Date 11/01/2012 xvi Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CLINICAL GUIDELINES AND PROTOCOLS INTRO 4 Page xvii TOC This Manual sets forth Standard Operating Procedures, Policies, and Protocols deemed by MCHD EMS to be within the acceptable standard of medical care and are the only ones to be utilized by MCHD personnel. It is specifically recognized that there are acceptable variations from these procedures and protocols, which may also satisfy the standard of care. Therefore, variations from these procedures and protocols are not necessarily deemed to be outside the standard of care. These are diagnostic-based protocols; meaning that the paramedic should arrive at a working differential of what the main problem is with the patient and then select the protocol which best matches that primary differential. Should a patient fall under a given protocol based upon the paramedic’s differential, but not fit the criteria and history requirements to activate the standing orders, EMS personnel shall initiate the most appropriate treatment for the most emergent clinical problem within their respective scope of practice. Personnel should consult with the on-duty Supervisor ASAP for any additional assistance or support. Each patient may be treated with one protocol (for one differential) or with multiple protocols simultaneously (if the paramedic finds more than one concurrent illness or injury). Should a paramedic who is treating a patient with more than one simultaneous protocol be faced with choosing among medications or therapies within those protocols that conflict with one another, the following guidelines are to be used to determine which therapy shall prevail: 1. Treat the problem that is more life threatening first. Evaluate the problem against the “ABC’s” and intervene in the one(s) that affect the airway first, then the one(s) that affect breathing and last the one(s) that affect circulation. For example, if you have a patient who is suffering from cardiac ischemia and pulmonary edema, treat the pulmonary edema (“B”) first then the cardiac ischemia (“C”). 2. If the above test does not resolve the conflict, treat the problem that is more underlying first. For example, if assessment of the present history indicates that hypertensive crisis caused pulmonary edema, then treat the hypertension first. 3. If a dysrhythmia is to be treated, do so in the following order: First: Treat heart rate Second: Treat rhythm Third: Treat B/P. Note: If hypotension and dysrhythmias are believed to be secondary to low intravascular volume, IV fluid infusion may be used first. When a patient changes from one algorithm to another algorithm, do not administer more than the maximum total dose of a medication. EKG Monitoring may be initiated and vascular access may be obtained in any patient at the discretion of the Paramedic. Oxygen may be administered to any patient at any time, but should be administered to maintain a saturation by pulse oximeter of 95% or greater. In addition to those therapies expressly listed in the SDOs, the following medications are available for use on standing order in any cardiac arrest situation where there is evidence that they are indicated: Naloxone, D25% or D50%, Thiamine Revision Date 11/01/2012 xvii Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CLINICAL GUIDELINES AND PROTOCOLS INTRO 4 Page xviii TOC Categorization of SDOs: The treatment protocols have been divided into groups for ease of utilization. The categories have been indexed such that any future change in a particular protocol may be performed without difficulty. The format developed facilitates organization and rapid access to the correct protocol for a given situation. The treatment categories are the following: • • • • • • • • • • • • Clinical Guidelines Adult Behavioral Emergencies Adult Cardiac Emergencies Adult Environmental Emergencies Adult Medical Emergencies Adult Respiratory Emergencies Adult Trauma OB / GYN Emergencies Procedures Medication Reference Special Response Scenarios Appendix Pedi Behavioral Emergencies Pedi Cardiac Emergencies Pedi Environmental Emergencies Pedi Medical Emergencies Pedi Respiratory Emergencies Pedi Trauma Structure of Individual Standing Orders: The outline format of the SDOs is strictly for rapid and uniform reference and does not imply or direct a mandatory sequence for patient care. • • • • • • Criteria and History Section: Outlines clinically important parameters that when assessed will assist in the application of a specific SDO. It provides a list of possible Historical, Physical and/or EKG findings that may be present if a specific SDO is applied. Assessment Section: Lists and emphasizes the assessment parameters, diagnostic tests and/or devices which should be a primary consideration for the selected SDO. When obtained, the items listed could be advantageous in making a competent clinical decision regarding a treatment path. Primary Interventions Section: These are considered essential interventions for the specific SDO in non-sequential order. The interventions in this section represent the “priorities” that should be considered upon initial patient contact and reconsidered throughout the call. All Interventions in the Primary Interventions section are considered standing orders, requiring no on-line consultation. Secondary Interventions Section: These are considered optional interventions for the specific SDO in non-sequential order. All optional Interventions in the Secondary Interventions section are considered standing orders, requiring no on-line consultation. Consult Section: Interventions that require online medical authorization prior to application. The text on the right side of each guideline represents thoughts or actions that should be constantly evaluated and play a part in the decision making process. Revision Date 11/01/2012 xviii Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CLINICAL GUIDELINES AND PROTOCOLS INTRO 4 Page xix TOC Treatment and management principles common to the care of every patient are detailed at the beginning of each section, and are specific for each section. For example, every trauma patient should initially be assessed and managed the same way, as should every medical patient and OB/GYN patient. Therefore, each individual SDO addresses the initial assessment and management by referring to the general assessment and management SDO for that section instead of listing the same assessment parameters on each SDO. While no fixed set of rules can span the variety of situations which may be encountered by EMS personnel, the following SDOs, protocols, policies and procedures are comprehensive guidelines covering most situations that are routinely encountered. The implementation of a standing order is at the discretion of the MCHD employee providing care, or the employee with the highest ranking medical certification. EMS personnel should use the protocol that is most closely associated with the patient’s condition. Once MCHD personnel begin treatment under a particular SDO, the SDO serves as indirect medical control and should be used as a guideline for patient care until one of the following situations occurs: 1. The patient’s condition changes: If the patient’s condition changes to another treatable rhythm during or after treatment, refer to that specific SDO, or contact the on-duty Supervisor for a consult for guidance. Whenever a patient changes from one algorithm to another algorithm, DO NOT administer more than the maximum total dose of a medication. 2. The next step in the protocol is inappropriate for the patient: For example, the medic believes that completing the next step in the SDO may cause harm to the patient such as giving a medication that the patient is allergic to, or potential side effects from a medication that may worsen the patient’s condition. In these circumstances, contact the on-duty Supervisor for consultation. If a clinical improvement noted after initial interventions, further standing orders may be withheld based upon the paramedic’s clinical judgment. Some situations may necessitate the concurrent use of more than one SDO. Always treat the problem which poses the greatest risk to life or loss of limb. If undeterminable, treat the most underlying problem first. Initiation of patient transport is always encouraged at the earliest possible time in the flow of patient care. A delay in transport may occur in rare circumstances; however, the delay should be well justified and only occur when a treatment considered a "critical intervention" cannot/should not be performed during transport. Treat to the point of significant relief or appropriate clinical improvement. Revision Date 11/01/2012 xix Montgomery County Hospital District-EMS Clinical Guidelines – Introduction DEFINITIONS INTRO 05 Page xx TOC The following words and terms, when used in this Manual, shall have the following meanings, unless the context clearly states otherwise. ABANDONMENT: Leaving a patient without medical care once patient contact has been established, unless emergency medical services (EMS) personnel are following a physician directive or the patient signs a release; turning the care of a patient over to an individual of less training when advanced treatment modalities have been initiated to include, but not limited to, IV’s, intubation, and drug therapy. TDSHS Rule §157.2 (1) A/C: Antecubital fossa ACLS: Advanced Cardiac Life Support ADVANCED DIRECTIVE: A legal document which defines a patient’s wishes for initiation or withholding life saving interventions, up to and including CPR. ADVANCED LIFE SUPPORT (ALS): Emergency prehospital treatment that involves invasive medical interventions including but not limited to, the delivery or assisted delivery of medications, defibrillation, and advanced airway management. AFIB: Atrial Fibrillation AHA: American Heart Association AIR MEDICAL PROVIDER (AMP): Rotor-wing transport service utilized by field crews for transportation of patients from scene or nearby landing zone to a medical facility. ALARM: MCHD’s communications/dispatch center. APAP: Acetaminophen ASA: Aspirin ASPN: Associated Symptoms and Pertinent Negatives ATTENDANT: An MCHD employee authorized at the attendant level. AUTOMATIC VENTILATOR: Time-cycled, pressure-controlled devices used to assist ventilations when an endotracheal tube is in place. BASIC LIFE SUPPORT (BLS): Emergency prehospital care involving noninvasive medical interventions. The provision of basic life support may be under the medical direction and/or supervision and control of a licensed physician. BP or B/P: Systolic blood pressure BRADYCARDIA: Heart rate less than 60 beats/minute Revision Date 11/01/2012 xx Montgomery County Hospital District-EMS Clinical Guidelines – Introduction DEFINITIONS INTRO 05 Page xxi TOC BSA: Body surface area BVM: Bag valve mask CABC: C-spine, Airway, Breathing, Circulation C-SPINE: Cervical spine CENTRAL LINES: Means any IV catheter device which gains access to a patient’s central circulation. COPD: Chronic Obstructive Pulmonary Disease CONSENT: Before providing care to a conscious and alert victim, consent should first be obtained. To obtain consent you should tell the victim who you are, ask the patient if they are willing to accept your help, inform them what it is that you plan to do to help them, ensure that they completely understand what you are saying, and then allow the patient to either give or not give consent. CPAP: Continuous Positive Airway Pressure CPR: Cardiopulmonary resuscitation DELEGATED PRACTICE: Permission given by a licensed physician either in person, by treatment protocols or by standing, orders to specific prehospital providers authorizing prehospital medical care. DEPENDENT LIVIDITY: Venous pooling of blood in dependent body parts causing purple discoloration of the skin, which does blanch with pressure. DUTY TO ACT: Most professional rescuers have a duty to act at the scene of an emergency (especially if you are being paid or working as a first responder etc...). In other words, for the exception of safety concerns, one should go to the scene of an emergency when on duty. EJ: External jugular vein ECG (EKG): Electrocardiogram EMERGENCY: Any combination of events or circumstances that results in injury or illness requiring immediate medical care of a person or persons. Any situation declared an emergency by a licensed physician should be considered to be an emergency by the MCHD EMS. Situations where there is doubt about whether an emergency exists should be treated as emergencies. EMERGENCY MEDICAL CALL: Means a medical situation in which an immediate response to a scene is required to prevent life or limb-threatening medical deterioration of a person requiring emergency medical treatment. Revision Date 11/01/2012 xxi Montgomery County Hospital District-EMS Clinical Guidelines – Introduction DEFINITIONS INTRO 05 Page xxii TOC EMERGENCY MEDICAL SERVICES: A service with a coordinated arrangement of resources (including personnel, equipment. and facilities) organized to respond to medical emergencies and/or an individual’s perceived need for immediate medical care. EMERGENCY MEDICAL PERSONNEL: Those individuals certified or licensed by the Department of State Health Services (DSHS) to provide emergency medical care. EMT-B; EMT-I; EMT-P; Lic-P. EMERGENCY MEDICAL TREATMENT: Means those skills, techniques and judgments, as defined by the Medical Director, which are intended to maintain, improve or prevent deterioration of a patient medical due to a medical condition. The treatment has also been deemed appropriate to be delivered by trained personnel at the scene of a medical emergency outside the hospital and/or during transportation to the hospital. EMERGENCY SERVICES: Those health care services provided to evaluate and treat medical conditions of recent onset and severity that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that urgent and/or unscheduled medical care is required. ET: Endotracheal FIRST AVAILABLE: It is the time after arriving at a destination facility that the medic crew is able to respond to another call. FIRST RESPONDER: Individuals who are certified as Emergency Care Attendants or higher by the Department of State Health Services (DSHS) and approved by the MCHD Medical Director to become first responders for MCHD. Due to their close proximity to emergency scenes, first responders may administer either basic or advanced life support prior to arrival of an MICU. FLUID BOLUS: Administration of 250-500 ml of NaCl 0.9% via rapid infusion in and Adult patient and 20 ml/kg in a pediatric patient. GCS: Glasgow Coma Scale GUIDELINES: Information in protocols and/or standard operating procedures that provide personnel additional information by which to make sound judgments or determine a course of action to determine a course of action. HHN: Hand Held Nebulizer ICE: In Charge Evaluation ICP: Intracranial pressure IN CHARGE: An MCHD employee authorized as the lead medic on a crew IM: Intramuscular Revision Date 11/01/2012 xxii Montgomery County Hospital District-EMS Clinical Guidelines – Introduction DEFINITIONS INTRO 05 Page xxiii TOC INTERVENOR PHYSIClAN: A physician licensed by the Texas Medical Board, who without having established a prior physician/patient relationship with an emergency patient, accepts responsibility for the prehospital care, and who shall provide proof of a current medical license when requested. IN SERVICE: A vehicle is considered in service if it is capable of response, patient transport or complete patient care. IO: lntraosseous IV: Intravenous IVP: IV Push for administration of medications J or j: Joule JVD: Jugular Venous distension KVO: Keep vein open; same as TKO. MASS CASUALTY INCIDENT (MCI): Any single occurrence resulting in multiple victims which taxes an EMS system’s ability to handle the victims’ entire emergency prehospital care needs and maintain adequate protection for the remainder of its service area. MCHD EMS: Montgomery County Hospital District— Emergency Medical Services MCHD EMS PERSONNEL: Individuals employed by the MCHD EMS Department are referred to in these guidelines as MCHD EMS personnel or employees. MDI: Metered dose inhaler. MEDICAL CONTROL: Medical Control is a MD or other authorized person who may authorize specific treatment of the sick and injured. MEDICAL DIRECTOR: A physician licensed by the Texas Medical Board who is responsible for all aspects of the operation of an EMS system concerning the provision of medical care. The Medical Director is that Physician who provides direction and guidance of the EMS system and who authorizes EMS personnel to perform specific skills. MOBILE INTENSIVE CARE UNIT (MICU): A vehicle that is designated for transporting sick or injured individuals, staffed by at least one EMT-Paramedic and another certified individual at or above the level of EMT-Basic, and meets minimum equipment requirements established for such vehicles by the TDSHS. MUTUAL AID: Emergency prehospital care provided in another EMS provider’s service area at the request of the other EMS provider in order to assist that provider in maintaining adequate Revision Date 11/01/2012 xxiii Montgomery County Hospital District-EMS Clinical Guidelines – Introduction DEFINITIONS INTRO 05 Page xxiv TOC EMS protection in its service area. Assistance provided by one provider to another whose resources are overwhelmed. NC: Nasal cannula is an oxygen delivery device used at a flow rate of 2-6 LPM. NEGLIGENCE: If a failure to follow the standard of care or it a failure to act results in someone being injured or causes further harm to the victim, then there is negligence. For example—failing to provide care, providing care beyond your level of training, providing inappropriate care, or failing to control behaviors that could result in injury are all considered negligence. NKDA: No Known Drug Allergies NON-EMERGENCY: Means a situation in which an immediate response to a scene, hospital, health care facility or other place is not required to prevent life or limb-threatening medical deterioration of a person. May include responses to assist calls for citizens of other agencies. NPO: Latin for ”nil per os”: nothing by mouth. NRB: Non-rebreather mask with oxygen at 10-15 LPM or enough to maintain adequate reservoir bag inflation. NS: Normal Saline NTG: Nitroglycerin N/V: Nausea / vomiting OFF-LINE MEDICAL CONTROL: Delegated practice through the use of the SDO’s, Protocols and Policies and procedures. ON-LINE MEDICAL CONTROL: Direct communication via either in person, or through the use of a phone line, radio, or other form of telecommunication. OOH-DNR: Out of hospital do not resuscitate order OPQRST: An acronym used to help in the description of pain. O-onset of symptoms; Pprovocation; Q-Quality; R-radiation; S-severity; T-time OUT OF SERVICE: A vehicle is considered out of service if it is incapable of response, patient transport or providing patient care. PATIENT CONTACT: The point when initial contact is made between the EMS provider and the patient. PEDIATRIC PATIENT: Patient < 45 kg in weight PEEP: Positive end expiratory pressure Revision Date 11/01/2012 xxiv Montgomery County Hospital District-EMS Clinical Guidelines – Introduction DEFINITIONS INTRO 05 Page xxv TOC PMS: Pulse, Motor, Sensation assessment parameters PPV: Positive Pressure Ventilation device such as: mouth-to-mask ventilation with oxygen, twoperson bag valve-mask technique with oxygen PR: Per rectum PRE-HOSPITAL CARE: Care provided to the sick or injured by EMS personnel in an out-ofhospital environment. PRE-HOSPITAL PROVIDERS: All TDSHS certified or licensed personnel providing medical care in an out-of-hospital environment. PRN: As needed PROTOCOLS: Written instructions providing pre-hospital personnel with a standardized approach to commonly encountered problems in the out-of-hospital setting, typically in regard to patient care. Protocols may include standing orders to be implemented prior to, or in lieu of, establishing communication with direct medical control. q: Every REFUSAL OF CARE: Every conscious and alert person has the right to refuse medical treatment. If we treat patients without their consent, this could be interpreted by the patient as battery. (*Note: Patient should be at least 18 years old or legal adult to give consent. Minors CANNOT refuse treatment) ROSC: Return of spontaneous circulation ROSR: Return of spontaneous respiration SALINE LOCK: Intravenous access device which allows venous access without the use of IV tubing or continuous fluids. SAMPLE: An acronym used to gather patient history during an event. S-signs/symptoms; Aallergies; M-medications; P-prior history or pertinent past medical history; L-last oral intake; Eevents leading up to the incident SECOND AVAILABLE: A vehicle and its crew are considered second-available when they are capable of taking a response, transporting a patient and providing patient care. SL: Sublingual S/S: Signs and symptoms Revision Date 11/01/2012 xxv Montgomery County Hospital District-EMS Clinical Guidelines – Introduction DEFINITIONS INTRO 05 Page xxvi TOC STANDARD OF CARE: Care equivalent to what any reasonable, prudent person, of like certification or license level would have performed in a similar situation based on local or regionally adopted standard emergency medical services curricula. CLINICAL GUIDELINES (SDO’S): Standing Orders are protocols which allow certain procedures to be carried out by properly certified personnel under certain defined circumstances before requesting a Supervisor consult for on-line medical direction. STANDARD OPERATING PROCEDURES (SOP): Standard Operating Procedures are those methods of operation which provide a consistent form of day to day operation. Standard Operating Procedures include protocols, special protocols, guidelines, and standing orders and establish the organizations Standard of Care. SQ: Subcutaneous Injection SUPERVISOR CONSULT: Term used to describe On-Line Medical control via MCHD EMS Supervisory Personnel for the purpose of requesting additional treatment options TACHYCARDIA: A heart rate > 100 beats/minute TBSA: Total body surface area TCA: Tricyclic antidepressant TCP: Transcutaneous pacing TC UNIT: Transfer care units. Specifically assigned crews and ambulances whose primary task is to transfer non-emergency patients. TDSHS: Texas Department of State Health Services TRAUMA CENTER: A Hospital who has been specially designated for the care of trauma patients. VAGAL MANEUVERS: Having the patient cough, or holding their breath while bearing down in an attempt to slow their heart rate. VITAL SIGNS (V/S or VS): A term to indicate taking a patient’s blood pressure, pulse, respiratory rate and pulse oximetry. VOLUNTEER: An individual who provides services without expecting or receiving money, goods, or services in return for providing those services, except for reimbursement for expenses necessarily incurred in providing those services. Revision Date 11/01/2012 xxvi CLINICAL GUIDELINES This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines GENERAL THERAPIES CG 01 Page 1 TOC The following procedures, therapies, and medications are authorized above and beyond those noted in a specific protocol for use at the EMS provider’s discretion. Thiamine Thiamine may be administered to any adult patient any adult patient when the provider has any reason to suspect malnutrition. Thiamine should be given as 50 mg IM and 50 mg IV/IO. If an IV cannot be established, the provider may administer the entire 100 mg IM. Thiamine should be given prior to the initial administration of Dextrose administration. Dextrose Dextrose may be administered to any patient whose blood glucose determination is < 80 mg/dl. In the hypoglycemic patient with an intact gag reflex when an IV cannot be establised, dextrose may be given orally as a glucose paste. A patient patient refusal should not be accepted from any patient whose blood glucose level is < 80 mg/dl without consult. Vascular Access Unless specifically limited or prohibited by a particular protocol, advanced EMS personnel (EMT-Intermediates, EMT-Paramedics), may obtain vascular access on any patient at their descretion. EMT-Basics may attend patients from inter-facility transports with a pre-existing saline lock, as long as there is absolutely no fluid or medications being administered to the patient through the saline lock. Oxygen Oxygen may be administered to any patient. It should be administered to every patient who demonstrates hypoxemia by clinical presentaion and/or pulse oximetry <95% SaO2. Endotracheal Intubation Advanced EMS personnel may secure the airway of any patient they believe is at risk for airway compromise or who requires positive pressure ventilation. The airway may be secured with endotracheal intubation, so long as the patient does not have any contraindications to this procedure. Endotracheal intubation may be by oral or nasal route based on clinical indications and contraindications. Pharmacologocially Assisted Intubation and/or surgical airways require consultation and approval prior to application. Medications may be given via the endotracheal tube if: a. Vascular access is delayed and intubation is accomplished b. Auscultation reveals clear lung fields c. Medications given via the ET tube for the adult require higher doses and dilution, and are very susceptible to bronchial/alveolar infiltrates and alveolar wall disturbances. d. The "bolus" dose of any adult medication given via ET is to be doubled from the standard IV dose. e. Medications which may be given via ET are: i. Naloxone ii. Atropine iii. Epinephrine iv. Lidocaine Revision Date 11/01/2012 1 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines GENERAL THERAPIES CG 01 Page 2 TOC f. These medications should be instilled through a catheter passed beyond the tip of the Endotracheal Tube, and followed by several positive pressure ventilation’s via a bag-valve device attached to the Endotracheal Tube. Acetaminophen May be administered PO or PR to any febrile patient (without contraindications) as 975 mg for adult and as per dosing chart for pediatric patients. General Pediatric Therapies The number of encounters with children is far less than with adults. These protocols therefore address situations where advanced procedures in the field can directly affect a child's survival. Control of the airway and rapid transport are the underlying principles of the pediatric protocols and best serve the needs of the pediatric patient. 1. Airway and Ventilation A Airway management by mouth-to-mouth-and-nose, mouth-to mask, or bag-valvemask ventilation should be used in neonates, infants, and children as a first maneuver for providing assisted ventilation. B Remember that the correct position to maintain the optimal airway is age-dependent. In pediatric patients with suspected trauma, the airway maneuver of choice is a modified jaw thrust combined with cervical spine stabilization. C Oxygen should always be provided at high concentration in the pediatric patient and should be humidified when feasible. There are no contraindications to high concentration oxygen in the pre-hospital setting for the pediatric patient. 2. Intubation A When noted in the protocols, or when other maneuvers used to ventilate the pediatric patient are inadequate, Endotracheal Intubation should be attempted. B Children suspected of having croup/epiglottitis might experience life threatening laryngeal spasms and close off their airways exercise extreme caution during attempts to intubation. 3. Intravenous, Saline Lock or Intraosseous Access There should limited number of attempts for each method in obtaining access to pediatric patients. Intravenous attempts should always precede IO access. 4. Pediatric Drug Dosage and Fluid Administration A For drug dosage and fluid administration, refer to both the Broselow Tape and the Pediatric Appendix. B When the patient is intubated and vascular access is not acheived, Lidocaine,, Epinephrine, Atropine, and Naloxone may be administered via the Endotracheal Tube. The initial dose of these medications via the Endotracheal Tube is the same as the IV/IO dose. These medications should be diluted to 3-5 ml total drug volume with Normal Saline (0.9% NS), instilled through a catheter passed beyond the tip of the Endotracheal Tube, and followed by several positive pressure ventilation’s via a bag-valve device attached to the Endotracheal Tube. C Initial fluid bolus administration should not exceed 20 ml/kg. Revision Date 11/01/2012 2 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DIAGNOSTIC TOOLS AND PROCEDURES CG 02 Page 3 TOC 1. Vital Signs A A complete set of vital signs should be obtained on all patients assessed, INCLUDING children and infants, within five (5) minutes of patient contact unless patient condition does not allow. B Patients refusing treatment / transport should have one complete set of V/S taken and charted, if the patient allows. C Patients transported to a hospital should have a minimum of two complete sets of V/S obtained and recorded. For patient contact and/or transport times shorter than 15 minutes in duration, it is acceptable to use vital signs obtained upon triage at receiving facility. D “Stable" patients with non life-or limb-threatening problems should have VS repeated every 15min. E “Urgent” to “critical” patients should have V/S taken and documented every 5 min. a. Patients who are being transferred (Non-Emergency) should have at least one set of V/S taken. If the initial V/S are out of normal limits, then a second set should be taken. b. A complete set vital signs (V/S) are defined as: • Respiratory Rate • Pulse and Heart Rate The term "heart rate" refers most correctly to the rate of electrical depolarization (usually ventricular) noted on the ECG monitor. “Pulse rate" refers to the palpable rate of perfusion noted at a pulse point or displayed by the pulse oximeter. While in most patients these are identical values, this is not always the case. When reporting the rate on the ECG monitor, use the term “heart rate." Crews should be certain that this rate correlates with the perfusing or palpable pulse rate. • • Special Allowance: In the critical patient where time is a factor, the EMS personnel may use palpable pulses to estimate and document blood pressure. The acceptable values are as follows: − Palpable radial pulse: Systolic of 80 mm/Hg − Palpable brachial pulse: Systolic of 70 mm/Hg − Palpable carotid pulse: Systolic of 60 mm/Hg Capillary Refill Capillary Refill may be used as an adjunct to blood pressure in assessing the perfusion status of any patient. Capillary refill may be substituted for blood pressure in the infant < 1 year of age. Capillary refill is not an acceptable substitute for B/P in the patient > 1 year of age. Blood Pressure The accuracy of an obtained blood pressure is influenced by many factors, such as the size of the cuff used. A cuff too small for the arm will yield an elevated blood pressure, while one too large will result in a lower Revision Date 11/01/2011 3 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DIAGNOSTIC TOOLS AND PROCEDURES CG 02 Page 4 TOC than normal reading. The cuff should easily go around the patient’s upper arm, but the air bladder should not overlap itself. The cuff itself should be 2/3 the length of the patient's upper arm. 2. 3. A systolic B/P (palpated B/P) is acceptable ONLY: − As an additional vital sign in the non-urgent patient in whom an auscultated B/P has already been obtained and was within normal limits. − In the critical trauma patient in whom serial palpated B/P's are being obtained. − In the patient in whom an auscultated B/P absolutely can not be obtained. Blood Glucose A Blood glucose should be assessed on all patients with altered mental status. This includes patients who experience a seizure or a syncopal episode. B A blood glucose measurement may be performed on any patient at the discretion of the EMS personnel. C Those patients with altered mental status which appears to be secondary to trauma should also have their blood glucose assessed IF such assessment will not delay definitive interventions, such as airway management, cervical spine immobilization, hemorrhage control, transport, or vascular access. D A patient refusal may not be accepted from any patient whose blood glucose level is not at least 80 mg/dl. A Medical Consult is required prior to refusing anyone with a blood glucose of < 80 mg/dI. E Blood glucose should be assessed on all patients 1 year of age or less in distress, regardless of findings or complaints. The only exception would be the pediatric patient who is suspected of having epiglotitis. F After administering D50%, the blood glucose value will remain elevated for quite some time as the cells attempt to uptake the glucose. Therefore, blood glucose measurements taken shortly after the administration of dextrose may not reflect improvement of the intracellular hypoglycemia. If a repeat blood glucose measurement is used, wait at least 10 min after D50% administration. G The patient’s clinical status as well as serial blood glucose measurements should be used to determine whether to administer additional dextrose. Temperature A Temperature should be assessed on the following: • Pediatric seizure patients • Patients with suspected diagnosis of sepsis • Patients whose complaints or findings indicate febrile activity • Patients whose findings indicate hypothermic or a other hyperthermic states (Heat Stroke) • Drowning patients who present in cardiopulmonary arrest. • Any patient being treated with therapeutic hypothermia. Use NG or OG in intubated patients only. Revision Date 11/01/2011 4 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DIAGNOSTIC TOOLS AND PROCEDURES CG 02 Page 5 TOC • 4. 5. Axillary temperatures are not acceptable. • When reporting or documenting a temperature value, indicate the source (oral, rectal, temporal, esophageal, or tympanic). ECG Monitoring A The patients ECG should be assessed within 5 min if patient condition allows. B Record a strip of ECG of at least 12 seconds duration. C Record any changes in rhythm or any significant changes in rate. D Record "pre" and "post" ECG strips before and after any intervention that should affect the cardiac rhythm or rate (meds, electrical therapy, etc.) E 12 LEAD a. 12-Lead ECG should be assessed on any patient who is experiencing cardiac related signs and symptoms. b. 12-Lead ECG should be obtained prior to a 3 lead ECG on any patient who is experiencing cardiac related signs and symptoms. c. If possible, a 12-Lead ECG should be obtained prior to any treatment (O2, NTG, ASA) on patients experiencing cardiac related signs and symptoms. F 3 LEAD a. A 3 lead ECG should be assessed on all patients with complaints or presentation of any of the following: • Chest pain (or other possible myocardial ischemia pain) • Shortness of breath and/or dyspnea • Syncope • Dizziness • Nausea / vomiting • Hypotension/hypertension • Tachycardia, bradycardia, and/or irregular heart beat • Altered mental status Pulse Oximetry A Pulse Oximetry should be used to evaluate the oxygen saturation status of all patients in whom hypoxia or ischemia is suspected. B Pulse oximetry may be used to titrate oxygen delivery, and permits the EMS personnel to utilize delivery devices or flow rates that are most appropriate for patient condition. C Oxygen should be administered as necessary to maintain a SaO2 equal to or > 95%. • Special Allowance: While this may be our goal, it should be noted that patients with significant COPD history may not be able to achieve SaO2 of 95%. D Pulse Oximetry readings are accurate only if the probe is able to "see" the arterial blood flow. The patient is well perfused. a. The probe should be firmly attached to a clean finger or toe. Nail polish may occlude the probe's light beam, so unpolished nails are preferred. Revision Date 11/01/2011 5 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DIAGNOSTIC TOOLS AND PROCEDURES CG 02 Page 6 TOC Hypotensive, hypoperfused, or peripherally vasoconstricted patients are generally not good candidates for pulse oximetry. (pulseless or cold extremities) c. The heart rate from the pulse oximeter matches the patient's palpable pulse rate. b. Revision Date 11/01/2011 6 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines MEDICATION STANDARDS CG 03 Page 7 TOC 1. Medications may only be given: a. By an approved MCHD EMS Intermediate or Paramedic. b. When administered according to MCHD EMS protocol or by specific written orders. c. By direct order via a medical consult 2. Medications and IV fluids should be checked prior to administration to the patient to ensure that they are not expired and that they are clear and free of any contaminants. 3. All patients SHOULD be asked for their allergies to medications prior to any medication administration. 4. The crewmember requesting and receiving orders are responsible for confirming the orders. 5. If, at any time, an order is unclear, ask for clarification. 6. When more than one IV bag is infused in a patient prior to the arrival at the receiving hospital, IV bags should be labeled to indicate the bag number currently being infused. 7. Any bag which has medications added shall be clearly labeled with the name of the drug, the quantity added, the time when the bag was hung, and the initials of the person preparing the bag for infusion. 8. The In-Charge is responsible for keeping all medications current and up to date as well as, control of the controlled substance box. (Refer to Transfer Care (TC) / Special Event Unit Authorization) 9. When any medications are administered, they should be documented on the patient care report. Revision Date 11/01/2012 7 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PROTOCOL DEVIATIONS CG 04 Page 8 TOC This policy manual is an overview and summary of MCHD policies and procedures that are currently in effect. As policies and procedures for the Clinical Department are revised, changes shouldbe communicated to employees through standard communication channels. It is difficult to cover all situations that may arise and challenge operations personnel in their efforts to provide timely, compassionate and quality patient care to residents and visitors of Montgomery County. Therefore, the policies and procedures contained in this manual constitute guidelines only. Any significant clinical issues should be considered on a case-bycase basis and should take into consideration any and all extenuating circumstances surrounding the event. In the interest of patient care should any deviation of SDO be preformed, employees shall complete an Unusual Occurrence Form and forward it to the Clinical Department for review with the Medical Director. The Medical Director for MCHD EMS is the final authority for all clinical and patient care issues. Revision Date 11/01/2012 8 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines SUPERVISOR NOTIFICATION CG 05 Page 9 TOC MANDATORY SUPERVISOR NOTIFICATION System certified providers operating within the MCHD EMS System do so under the authority of the Medical Director. As such, any incident which potentially has an adverse or negative impact on the patient or system should be immediately reported to the on duty Supervisor as soon as practical after the completion of the call so that an investigation may be initiated if warranted. Supervisor notification should include, but not be limited to the following: • Cardiac and/or respiratory arrest occurring after administration of a controlled substance. • Cardiac arrest occurring after administration of a paralytic agent. • Cardiac arrest occurring after administration of an antiarrhythmic agent in a previously stable patient. • Any adverse affect after administration of a thrombolytic agent. • Any attempt (successful or unsuccessful) at needle and/or surgical airways. • Incorrect medication administration or use (i.e., excessive amount, wrong dose, route, etc). • Any time the Patient Safety Restraint and/or Patient Safety Sedation procedures are utilized. • Any cardiac and/or respiratory arrest or patient injury while attempting physical restraint. • Any unusual circumstance or intervention that potentially causes or caused patient harm. • A provider has operated outside of his/her level of certification, training, and/or level of authorization (i.e., state certified Paramedic, who is authorized by the Medical Director at the EMT-B level, initiating an IV or performing endotracheal intubation). • Any potential employee exposure If any of the the above incidents occur, the Supervisor is responsible for contacting the Assistant Director EMS - Clinical Services appropriately. Revision Date 11/01/2012 9 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PATIENT STATUS CG 06 Page 10 TOC Patient status updates allow for the prioritization of the patient's clinical status. When crews update the patient status it signifies that the crew has recognized the urgency of their patient. Additionally, it allows supervisory, and alarm personnel, as well as, receiving facilities to react accordingly. 1. 2. 3. Priority 1 (Critical) A Critically ill or injured patient (immediately life-threatening illness or injury) needing immediate intervention. B Examples might include: a) Cardiac arrest or post cardiac arrest b) Head injury with GCS < 8 c) Penetrating trauma to head, neck, chest, or abdomen. Priority 2 (Urgent) A Potentially life-threatening illness or injury. B Examples might include: a) GCS 8 -12 b) Altered level of consciousness c) Status epilepticus d) Unresponsive patient e) Unstable vital signs and/or clinical signs of shock Priority 3 (Stable) A Non-urgent condition which may require medical attention, but not immediate treatment. B Examples might include: a) GCS 15 b) Stable vital signs c) Minor Injuries d) "Hemodynamically stable chest pain with no evidence of ischemia" Revision Date 11/01/2012 10 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines RADIO REPORT AND CONSULT GUIDELINES CG 07 Page 11 TOC The following format should be used when contacting a Supervisor to receive patient care orders. 1. Badge Number 2. Transport time to facility 3. What orders you are asking for, i.e. c-spine clearance, pain management or any other below –the –line treatment options (Be specific on type of pain management wanted). 4. If requesting orders for RSI include Mallampati score. 5. Age of patient 6. Level of Consciousness and GCS. 7. Chief Complaint 8. Pertinent past medical history (specific to patient’s chief complaint now) 9. Vital Signs including a Blood Glucose Level and ECG rhythm interpretation 10. Treatment administered by EMS In the event that a consult is required and the EMS provider is unable to make contact with the Supervisor or receiving facility, the provider should complete an Unusual Occurrence form and forward it to the Clinical Department for review with the Medical Director. The Medical Director for MCHD EMS is the final authority for all clinical and patient care issues. Revision Date 11/01/2012 11 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines COMMUNICATIONS FAILURE CG 08 Page 12 TOC In the event that an EMS unit cannot make contact with the receiving facility or a Supervisor for specific orders beyond those stated within the intervention section of each protocol, EMS personnel are required to follow the interventions that are listed in a particular protocol. Under no circumstances may EMS personnel administer a drug/narcotic or perform a procedure for which they are not authorized. There are no exceptions to this policy. In the interest of patient care should any communications failure occur, employees shall complete an Unusual Occurrence Form and forward it to the Clinical Department for review with the Medical Director. The Medical Director for MCHD EMS is the final authority for all clinical and patient care issues. Revision Date 11/01/2012 12 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CHAIN OF COMMAND CG 09 Page 13 TOC 1. Authority A The In-Charge of the first arriving medic unit is responsible for all patient care activities and coordination of resources at the scene until that responsibility is delegated to another In-Charge or assumed by a field Supervisor. B During MCI’s and multi-unit responses (> 2 units) the field Supervisor assumes operational responsibility for coordination of prehospital resources. At this point incident command procedures are in effect. 2. Management A The scene of an emergency shall be managed to minimize the risk of further injury or death to the patient as well to other persons who may be exposed to the risks as a result of the emergency condition. Priority shall be placed upon the interests of those persons exposed to the more serious and immediate risks to life and health. B Medical management at the scene of a medical emergency includes a) Medical Evaluation. b) Medical aspects of extrication and all movement of the patient(s). c) Medical care d) Patient destination and transport decisions C EMS personnel shall not delegate delegate patient care to other EMS personnel whose scope of practice limits their abilities to treat a patient. a) Personnel trained in defibrillation may not hand over responsibility for defibrillation to personnel not trained in defibrillation. b) ALS Personnel treating a patient requiring ALS intervention, may not hand over responsibility for the patient to BLS personnel. Revision Date 11/01/2012 13 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines NON-MCHD PERSONNEL ON SCENE CG 10 Page 14 TOC General Information This policy establishes the guidelines for EMS personnel and identifies the limits that trained/civilian bystanders may assist during an emergency response. Certified/Licensed Individuals Wishing to Assist Individuals who possess valid EMS certification and/or other healthcare license but are NOT employed by MCHD, may be allowed to assist MCHD EMS personnel in rendering patient care under the following conditions: • The individual may only participate in patient care under the direct supervision of MCHD EMS personnel. • Individuals who possess advanced certification should NOT be permitted to administer invasive treatment UNLESS the Medical Director or Supervisor specifically approves such treatment. Such treatment should only be approved during Mass Casualty Incidents (MCI’s) when MCHD resources are strained. Non-Certified Bystanders The use of non-certified bystanders in an emergency situation is not recommended and should be reserved for instances when their assistance could make a crucial difference in the outcome of the situation. Common situations in which a non-certified bystander might assist include but not limited to the following: CPR, manual C-spine stabilization, and hemorrhage control, etc. It is appropriate to provide PPE to bystanders offering assistance in patient care activities. Thorough documentation indicating the justification for such assistance should be documented in the patient care report. Fire Department/First Responder Personnel Fire department personnel are responsible for all fire suppression, hazard control and heavy extrication. In all rescue and extrication operations, the role of MCHD EMS personnel is to direct patient care and advise rescue teams on phases of the operation which might compromise the patient's condition. Unless specifically trained to do so, MCHD EMS personnel should not direct the technical aspects of patient rescue. First responder personnel should be utilized in a manner that allows them to practice their assessment and treatment skills. Law Enforcement Law Enforcement is responsible for traffic control, control of disruptive bystanders and scene security. Law Enforcement personnel with specialized training in First Response/AED may be utilized in a manner that maximizes their training and best assists in the positive outcome of the emergency. Revision Date 11/01/2012 14 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines NON-MCHD PERSONNEL ON SCENE CG 10 Page 15 TOC On Scene Physician Texas State Board of Medical Examiners Rule 197.5 addresses “On Scene Physician intervention” and shall govern situations involving an on scene physician who offers assistance in treating patients. All physicians who are present at the scene of an emergency and who offer assistance should be treated with professional courtesy. Any physician who offers assistance will be required to provide proof of identity and credentials before being allowed to provide patient care on the scene. Below is a summary of the Rules governing Physician on Scene guidelines. Patient’s Doctor on Scene When a patient's private physician is on the scene of an incident and has provided the appropriate credentials, MCHD EMS personnel should comply with his/her directions concerning treatment of the patient to the extent that those orders are consistent with established protocols. On-line medical control should be notified of all on scene physician contacts wishing to assist. • When a physician elects to accompany his/her patient to the hospital, MCHD EMS personnel should respect the physician's wishes in the management of the patient during the entire course of patient care. • When the physician requests that the patient be transported immediately, MCHD EMS personnel should honor the physician’s requests with all reasonable haste after obtaining the patient’s consent. • It is not appropriate to re-evaluate a patient after the patient has been thoroughly evaluated by a physician and the physician has made an adequate report concerning the patient’s condition to the responding crew prior to transporting the patient. Additional information concerning the patient should be obtained from the physician, his/her representative or the patient, if necessary. • If MCHD EMS employees believe that the physician has not properly evaluated the patient, they should perform an assessment of the patient, provide all immediately necessary treatment, and move the patient to the ambulance for further assessment and treatment. • The patient’s physician may write orders beyond the MCHD EMS Clinical Guidelines. Employees shall attempt to carry out the physician’s orders if the orders do not extend beyond the employees’ training, certification, or capabilities and the employees are in direct contact with the patient. Revision Date 11/01/2012 15 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines NON-MCHD PERSONNEL ON SCENE CG 10 Page 16 TOC Disagreements with Physician(s) on scene • • • • • • • An employee who disagrees with a patient’s physician concerning the management of the patient, or who disagrees with the physician’s judgment concerning the use of the EMS system, should NOT express his/her disagreement to the physician; rather, the employee should discuss the matter with the on-duty Supervisor. Advise the physician that all MCHD EMS personnel function under written standing orders and/or on-line medical direction that have been established by the MCHD EMS Medical Director. Advise the physician that he/she may continue to offer assistance by providing advice to on-scene MCHD EMS personnel or assisting with patient care under the direction of MCHD EMS current Clinical Guidelines. If the physician insists on providing direction outside established guidelines, he or she should take complete responsibility for the care of the patient, including accompanying the patient to the hospital. Crew shall document all activities during transport. If the physician assumes responsibility for the care of the patient, MCHD EMS personnel should comply with his/her directions as long as those orders are consistent with established standing orders. If the orders proposed by the intervening physician are not consistent with MCHD standing orders, MCHD EMS personnel shall respectfully decline to participate in that specific care. In this event, employees shall immediately contact an MCHD EMS Supervisor. MCHD EMS personnel should document all events and interaction between an intervening physician and the crew, including direction given and care provided. Once direct contact with a physician ends, EMS personnel shall give a progress report to the receiving Emergency Department and Supervisor by radio or telephone. The Supervisor may then give additional orders or change previous orders if necessary, depending on the patient's condition. Revision Date 11/01/2012 16 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines MEDICAL AUTHORIZATION LEVELS CG 11 Page 17 TOC General Information Authorization: Authorization is separate from certification. Every provider should have a current certification issued by the Texas Department of State Health (TDSHS). The Medical Director is responsible for granting authorization. Authorization is required to provide pre-hospital or out-of-hospital care to any patient within the MCHD EMS System. Certification level does not necessarily dictate authorization level. The Medical Director may authorize any provider to function at any level as per TDSHS Rule 157.11 To Obtain Authorization: Prior to allowing any provider to function in a patient care delivery role, the applicant provides the following information: a. The individual’s name, date of birth, address, social security number, and home phone number. b. The position for which the individual is applying. c. All applicants should provide a copy of the most current Texas Department of State Health Services certification/licensure in accordance with the State of Texas Administrative Code, Title 25, Part I, Chapter 157, Subchapter C, Section 157.33, 157.34, 157.35 or 157.40. -The copy should clearly show the applicant’s name, certification/licensure number, and expiration date. d. A copy of a valid drivers license that clearly shows the applicant’s name, license number and expiration date. e. All applicants should meet the criteria to be insurable by the current vehicle insurance vendor contracted to the District. f. All applicants are required to have a current (less than 2 years) AHA Health Care Provider CPR OR an equivalent course completion card with legible signatures and the date of the course. g. The following certifications are preferred for all applicants or should be obtained within 6 months of hire or first available class: • Advanced Cardiac Life Support (ACLS) course completion card from the American Heart Association – for Paramedics only • Basic Trauma Life Support (BTLS) course completion card is recommended. PHTLS may be substituted – for Paramedics and recommended for Basic and Intermediates • Pediatric Advanced Life Support (PALS) or an approved equivalent pediatric course is recommended – for Paramedics only All initial applicants for employment as pre-hospital care providers with MCHD EMS will be required to successfully complete a written general knowledge examination from an approved test bank with an overall score of at least 80% , skills evaluation as per the Medical Director, interview process, and physical agility/health screening. Additionally, Revision Date 11/01/2012 17 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines MEDICAL AUTHORIZATION LEVELS CG 11 Page 18 TOC the applicant will be subject to a background check and verification of insurability with the contracted vehicle insurance provider. The applicant should be successful at each phase before moving on to the next phase. The Skills Evaluation will be scenario-based evaluations with specific skills as per the Medical Director interjected at key points (i.e. an EMTP skill evaluation might be based on an AHA-ACLS scenario with skill evaluations for ET Intubation, Defibrillation, Pacing, or IV establishment). Medical Authorization will be granted to an employee only after a probationary period in which the individual’s assessment, decision making, and treatment skills are evaluated. The Assistant Director EMS-Clinical Services shall establish a training and evaluation program for granting medical authorization. The Medical Director maintains authority over all employees’ ability to use medical skills. Therefore, the Medical Director or his designee may deny an employee the right to use his or her medical skills at any time during the course of employment with MCHD EMS. The Medical Director or his/her designee may: • • • • • • Require an employee to undergo counseling; Require an employee to submit to remediation, including but are not limited to Retraining, Testing, or Field/hospital preceptorship Place an employee on medical authorization probation Reauthorize an employee at another level Deauthorize an employee, Recommend to the Texas Department of State Health Services that the employee be decertified. To Maintain Authorization: 1. The employee should retain his certification/licensure with TDSHS. If, for any reason, there is a lapse in certification, the employee will be suspended immediately. Operations will be notified. The employee may not return to work in a patient care role until the problem has been rectified. The employee should show proof that TDSHS has reinstated the EMT certification/license. If any employee allows his/her certification to expire or be revoked more than once during employment, he/she will be de-authorized immediately. 2. The employee should maintain all of his/her card courses in current standing. If a card lapses, the employee will have thirty (30) days to replace that card. After the thirty (30) day period, the employee may be reauthorized to a lower level of practice and the Assistant Director EMS-Operations will be notified. Revision Date 11/01/2012 18 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines MEDICAL AUTHORIZATION LEVELS CG 11 Page 19 TOC 3. The employee should participate in Continuing Education (CE) in accordance with the State of Texas Administrative Code, Title 25, Part I, Chapter 157, Subchapter C, Section 157.38 and in accordance with the defined policies of MCHD EMS. 4. Attend all mandatory MCHD CE offerings. 5. If at any time the employee loses their EMS certification, driver’s license, or is a part of an incident that might impact their insurability, the employee shall immediately notify their immediate Supervisor or Assistant Director EMS-Clinical Services. The employee may be removed from active duty pending a review of the situation. 6. If at any time the employee is under investigation by a law enforcement agency or the Texas Department of State Health Services, the EMS Director or designee willd be notified immediately. The EMS Director shall determine the seriousness of the allegations as it relates to the individual's function as an employee. The employee may be removed from active duty pending a review of the situation. 7. No employee will function in an official capacity if they have any physical or mental impairment or disease which could reasonably be expected to either impair their ability to function or jeopardize the health and safety of the patient or public or fellow employees. If such a condition exists, the employee should immediately inform the On Duty Supervisor or higher authority. AUTHORIZED INTERVENTIONS BY LEVEL The following represents patient care activities to be performed by EMS personnel at their current level of authorization. All BLS activities are authorized on standing orders to be used as needed. Authorization for ALS activities is indicated in the specific protocol or procedure for each intervention. All interventions listed below indicated with a (*) require individual training and authorization by the medical director or his/her designee. Emergency Care Attendant (Basic Life Support) • Patient assessment • Pulse oximetry • Oxygen administration • Use of oral adjuncts including oral and nasal airways, bag-valve mask device and oral suctioning. • Provision of CPR as defined by the American Heart Association • Vital signs • Bandaging and splinting including traction splinting • Cervical spine immobilization • Manual techniques for airway provision, maintenance and support, relief of airway obstruction as prescribed by AHA • Control of external hemorrhage • Use of automatic CPR device* (Thumper) • Automatic external defibrillator* Revision Date 11/01/2012 19 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines • MEDICAL AUTHORIZATION LEVELS CG 11 Page 20 TOC Emergency childbirth Emergency Medical Technician • All skills listed for Emergency Care Attendant • Blood Glucose assessment • Aspirin administration (under direction of In-Charge EMT-P) • Nebulized Metered inhalers(under direction of In-Charge EMT-P) • Administration of oral glucose • Operation of CPAP device / portable ventilator Special Allowance: If 12-Lead ECG equipment is readily available and patient condition and time permits, it is appropriate for a properly trained BLS provider to ACQUIRE a 12-Lead ECG on patients (in the presence or at the direction of their In-Charge Paramedic) treated under the “Acute Coronary Syndrome” SDO. Emergency Medical Technician-Intermediate • All skills listed for EMT-Basic • Vascular access • Intraosseous infusion • IV Fluid administration • Administration of Nitrous Oxide (under direction of In-Charge EMT-P) • Administration of D50% (under direction of In-Charge EMT-P) • Administration of IV Thiamine (under direction of In-Charge EMT-P) • Administration of IV Naloxone (under direction of In-Charge EMT-P) • Orotracheal intubation • Use of Qualitative CO2 Detection * • Use of approved secondary Airway Device (Combitube)* • Use of PEEP • Blood specimen collection • MAST trousers Personnel authorized at the basic or intermediate level MAY NOT administer any controlled substance, including Pharmacologically Assisted Intubation (RSI) or medications that are not specifically approved in the Clinical Policy or the Protocol. Special Allowance: If 12-Lead ECG equipment is readily available and patient condition and time permits, it is appropriate for a properly trained ALS provider to ACQUIRE a 12-Lead ECG on patients (in the presence or at the direction of their In-Charge EMT-P) treated under the “Acute Coronary Syndrome” SDO. Revision Date 11/01/2012 20 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines MEDICAL AUTHORIZATION LEVELS CG 11 Page 21 TOC Emergency Medical Technician-Paramedic • All skills listed above • All routes of medication administration (IV, IO, ET, SQ, SL, PR, IM) • Obtaining and interpreting ECG • Obtaining and interpreting 12-Lead ECG • Vagal maneuvers • Defibrillation / Cardioversion • External Cardiac Pacing • Nebulized bronchodilation • Any other skill as directed by PII Emergency Medical Technician-Paramedic I or II (In-Charge Paramedic) • All skills listed above • Nasogastric intubation/lavage • External jugular cannulation • Nasotracheal intubation • Chest decompression • Surgical airway (with permission from on-line medical control)* • Pharmacologically Assisted Intubation (with permission from on-line medical control) • Pericardiocentesis (with permission from on-line medical control)* Emergency Medical Technician-Paramedic III • All skills listed above • All Therapies within the protocols including extended medical authorization and other special procedural skills as developed. • Consults while on scene and those related to patients in which PIII contact has been made (patients assessed by PIII and transported by another unit). Emergency Medical Technician-Paramedic IV (future level of authorization) Operations/Clinical Supervisor • All skills listed above • All Therapies within the protocols including extended medical authorization and other special procedural skills as developed. • On-line medical direction through radio and/or phone consults as requested by Field staff. Revision Date 11/01/2012 21 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines MEDICAL AUTHORIZATION LEVELS CG 11 Page 22 TOC EMS Director/Assistant Directors EMS-Clinical Services and Operations • All skills listed above • All Therapies within the protocols including extended medical authorization and other special procedural skills as developed. • On-line medical direction through radio and/or phone consults as requested by Field staff. Attendant level personnel may practice under the supervision of a fully authorized paramedic to the full extent of their authorization. Clinical authorization is assigned to an individual, and not the operational position. Practicing Beyond Your Certification MCHD EMS personnel who are asked by a physician, nurse, paramedic or other person to perform procedures that are outside of their level of training, certification, or protocol should adhere to the following guidelines: 1. Employees should inform the person giving the directive that their training, certification, and/or protocol does not cover the requested procedure and that they should respectfully decline to perform the procedure. 2. Employees should document the procedure requested, the name and position of the person who requested the procedure, and the outcome of the employee’s refusal to perform the procedure. Failure to follow this policy may result in the suspension and/or revocation of an employee’s medical authorization. Employees should not perform any skill that they have not been trained, certified, and authorized to perform. Employee – Student Relationship Employees enrolled in Texas Department of State Health Services (TDSHS) approved certification courses and assigned to a unit in a student capacity may perform advanced skills within the scope of the course in which they are enrolled. The skills are to be performed under the direct supervision of an approved preceptor and/or medical supervisor. All other rules and regulations regarding student conduct should be observed. Employees enrolled in TDSHS approved certification courses should not perform advanced skills beyond their current certification level while in the course of their normal job duties. Revision Date 11/01/2012 22 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PIII AND SQUAD AUTHORIZATION CG 12 Page 23 TOC The Paramedic III position is in place to allow for recognition as well as professional growth and development for employees who successfully complete this promotional process. Employees with P-III authorization may perform medical procedures and administer medications independently and without a Supervisory consult. The Clinical Department will monitor procedures and treatments performed by individual P-III’s for appropriateness as part of the Continuous Quality Improvement Process. In addition to “below the line” authorization by the Medical Director, P-III’s working a Squad unit may consult with field staff on the responding Medic unit WHILE ON SCENE. Crews are encouraged to utilize the P-III on scene for “below the line” orders to ensure a smooth transfer of patient care as well as provide additional, appropriate care before transfer to a medical facility is initiated. The Medical Director and Assistant Director EMS-Clinical Services have established an additional level of authorization that allows P-III’s working on a Squad to provide consults for a patient they have evaluated and released to a transporting unit. This authorization is granted after consideration of the following: • • • Review of responses and treatment provided prior to arrival of transporting unit Review of treatment/procedure orders provided for staff on the transporting unit while on scene for appropriateness. Continued monitoring by the Clinical Department as part of the Continuous Quality Improvement process This authorization is in effect ONLY when the authorized individual is working a Squad unit. P-III’s working or assigned to medic units MAY NOT provide consults for transporting units in any situation. Clinical and Operations Supervisors, Assistant Directors EMS-Clinical Services and Operations, the EMS Director and Medical Director may provide orders for transporting units in any situation. Revision Date 11/01/2012 23 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PARAMEDIC I PROMOTIONAL REQUIREMENTS CG 13 Page 24 TOC This policy establishes guidelines for Attendant Level Paramedics who have successfully completed the requirements to enter the ICE process and are awaiting final assignment to a preceptor. It is to be viewed as a provisional in-charge position typically occupied by an individual for a period of 3 – 6 months and should not to exceed 12 months. General Information The purpose of the Paramedic I position is to allow successful ICE candidates to grow professionally while waiting to complete the In-Charge Evaluation process. These individuals should have successfully completed each phase of the initial promotional requirements and have demonstrated Operational and Clinical proficiency as documented by Field evaluations and testing requirements. Entry into the evaluation process may be delayed for numerous reasons including but not limited to the following: • • • The number of employee vacancies in the Operations Division of MCHD may indefinitely delay assignment to a preceptor No preceptors are available to evaluate the candidate The candidate may have personal considerations that delay the evaluation process All Paramedic-I candidates completing the promotional requirements will be temporarily authorized to work at the Paramedic I level and may staff a unit with other employees within the MCHD organization at the following levels: • • Employees authorized at the Paramedic I position Employees authorized at the Paramedic II position or higher Under no circumstances will a Paramedic I be allowed to staff an MICU within the 9-11 system with any attendant level employee including EMT-B, EMT-I and EMT-P unless they are assigned to a transfer unit for a designated shift. While staffing a transfer unit the Paramedic I should operate within the system under the guidelines already established by the Assistant Director EMS-Operations. Once a candidate meets all of these requirements he/she should write a letter to the Clinical Department that includes: • What skills would you want your ideal P-I to have • What qualities make a good P-I • Why he/she wants to become a P-I • Brief summary of past experiences that might qualify applicants for the position (may be non-EMS related) • Strengths and weaknesses of the applicant and how they may impact ability to perform at this level Revision Date 11/01/2012 24 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PARAMEDIC I PROMOTIONAL REQUIREMENTS CG 13 Page 25 TOC When the Clinical Department receives a letter of intent from a P-I candidate the following should occur: • • • • • • • • Verify applicant is in good standing with all MCHD departments Verify status of DSHS certification on DSHS website Evaluation of documentation compliance Verify attendance of all mandatory C.E. Classes Verification of mandatory card classes as well as number of classes taught Analyze transport and refusal ratios in relation to peers Review field and station evaluation scores as documented by supervisors Review past annual performance evaluations The following process will be implemented to ensure that each candidate has been evaluated by a preceptor before receiving Clinical Authorization at the Paramedic I Level including but not limited to the following: • The Paramedic I candidate is working with a Paramedic II and the preceptor rides as a third member of the crew to obtain evaluations. In this instance the Paramedic I candidate should assume the responsibility of patient care for all responses. The preceptor should be authorized at the Paramedic II level or higher and is responsible for completing the appropriate evaluation forms that may include station and truck inspections as well as patient care evaluations. • Two Paramedic I candidates may be assigned to an MICU with a preceptor riding third for the entire shift. The preceptor should be authorized at the Paramedic II level or higher and is responsible for completing the appropriate evaluation forms that may include station and truck inspections as well as patient care. In this instance the Paramedic I candidates should alternate responsibility for patient care so evaluations may be obtained on each candidate. When a preceptor is evaluating two (2) Paramedic I applicants the crew may be evaluated for decision making as a team as well as individually while providing patient care. • Candidates may be authorized at the Paramedic I level for up to one year at the discretion of the Medical Director and/or Assistant Director EMS-Clinical Services if a preceptor identifies areas of improvement for the candidate. During this time the Paramedic I candidate may have specific goals and tasks to accomplish. At the end of the recommended time period the candidate may re-enter the formal ICE process assigned to a preceptor for a final evaluation period. If the candidate is successful he/she will complete the ICE process and be authorized at the Paramedic II level with a 90-day probationary period required by policy for all promotional processes within the MCHD organization. If the candidate is unsuccessful he/she will be re-authorized at the attendant paramedic level and cannot re-apply to the Paramedic I or ICE program for one (1) year. Revision Date 11/01/2012 25 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PARAMEDIC I PROMOTIONAL REQUIREMENTS CG 13 Page 26 TOC Although the Paramedic I position is not intended to be a permanent assignment there are other benefits for employees as well as the organization that can be identified including: • Employees who have successfully completed the required objectives may request to remain at the Paramedic I level for up to 30-60 days to have an opportunity to gain additional experience before entering the formal ICE process. These individuals should have documentation of proficiency from a preceptor at the Paramedic-II level or higher. • MICU’s may be staffed with two (2) employees authorized at the Paramedic I level which allows staff the opportunity to gain additional experience as well as allowing greater flexibility within the organization for staffing purposes. It should be noted that all decisions for medical authorization within the organization are at the discretion of the Medical Director and the Assistant Director EMS-Clinical Services and may reflect what is in the best interest of the MCHD organization. Revision Date 11/01/2012 26 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PARAMEDIC II PROMOTIONAL REQUIREMENTS CG 14 Page 27 TOC The In-Charge Paramedic is an important component of EMS in Montgomery County and requires a commitment to provide quality care to residents and visitors of the community. The In-Charge Paramedic is the role model and team leader for other MCHD employees and first responders, as well as other public safety agencies. Being an In-Charge Paramedic is not only about providing quality clinical care, but involves scene management, radio communications, coaching students and partners, understanding policy and procedure as well as many other non-clinical responsibilities. The purpose of the In-Charge Evaluation Program is to provide tools and resources for paramedics within the MCHD EMS system, allowing them an opportunity to develop professionally as well as personally. Our desire is to provide a program that focuses on the non-clinical aspects of the in-charge such as leadership abilities, interpersonal communications and coaching techniques. The clinical aspects of being an In-Charge Paramedic should be learned and refined while acting as an Attendant Paramedic on the ambulance. We are fortunate at MCHD to have a Medical Director who allows our InCharge Paramedics to delegate authority to attendants. This opportunity allows MCHD attendants to care for a large variety of patients under the tutelage of an experienced paramedic. Consequently, it is important that employees seeking authorization at the InCharge Paramedic level successfully complete each of the following components before applying to enter the ICE program. 1. The candidate should have current certification for PALS, BTLS, CPR and ACLS. 2. The candidate should have attended the following mandatory continuing education classes: Airway management, 12-Lead ECG and the Trauma CE that includes bilateral chest decompression, Pericardiocentesis, c-spine clearance and trauma termination. These 3 classes will be made available quarterly for those who were unable to attend the initial offerings. 3. Internal candidates should have a minimum of six (6) months field experience at the paramedic attendant level; however a minimum of one (1) year is preferred. Occasionally, MCHD will have the opportunity to hire experienced paramedics from outside the organization. It is not the intent of the Clinical Department to prevent experienced paramedics from entering the program. These applicants will be reviewed on a case by case basis and should successfully complete the 90-day probationary period before they will be considered for the program. During the probationary period they should be given specific goals and objectives to complete and they should meet all other requirements before entering the program. Once a candidate meets all of these requirements he/she should submit a current resume’ to the Clinical Department. Revision Date 11/01/2012 27 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PARAMEDIC II PROMOTIONAL REQUIREMENTS CG 14 Page 28 TOC When the Clinical Department receives a resume’ from a P-II candidate, the following should occur: • • • • • • • • Verify applicant is in good standing with all MCHD departments Verify status of DSHS certification on DSHS website Evaluation of documentation compliance Verify attendance of all mandatory C.E. Classes Verification of mandatory card classes as well as number of classes taught Analyze transport and refusal ratios in relation to peers Review field and station evaluation scores as documented by supervisors Review past annual performance evaluations • The candidate will be given written tests that incorporate the Policy & Procedure manual, general knowledge, current SDO’s, specific procedures and critical thinking. The applicant should have a minimum score of 80% in each area to continue the process. The ICE candidate may take the initial exam a total of two (2) times and will wait a minimum of thirty (30) days before taking the exam a second time. If unsuccessful after the second attempt the ICE candidate will not be eligible to enter the program for a minimum of six (6) months. At the end of six months it is the decision of the Medical Director and the Assistant Director EMS-Clinical Services whether or not the candidate may attempt to re-enter the program. • After successful completion of the written exams, the candidate will complete scenario testing that incorporates application of SDO’s, specific procedures as well as critical thinking skills. Once the candidate successfully completes each of these components he/she should enter the program and be assigned a preceptor. This second component of the evaluation process lasts approximately 4 weeks. (Additional shifts may be recommended and/or required upon recommendation of the preceptor and/or Assistant Director EMSClinical Services). The Clinical Department should meet regularly with the candidate and preceptor to provide support and feedback, monitor call volume and types of calls as well as progress made by the candidate. Upon successful completion of this component, the candidate should proceed to the final phase of the evaluation process. This component requires the candidate to assume the lead role on the unit while being evaluated by a senior in-charge acting as the attendant. This third component lasts approximately two weeks; however, additional shifts may be recommended/required by the preceptor or Assistant Director EMS-Clinical Services. The ICE process is to be viewed as an evaluation period. The candidate should demonstrate profiency in duties and responsibilities normally associated with In-Charge position without guidance. Once successfully completed, the candidate will be released from the ICE program with the authorization and privileges associated with the In-Charge position. The promotional Revision Date 11/01/2012 28 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PARAMEDIC II PROMOTIONAL REQUIREMENTS CG 14 Page 29 TOC date will replace date of hire for annual evaluations and the candidate should complete a ninety (90) day probation in his new position. Upon successful completion of the program the applicant should be required to have an exit interview with members of the Clinical Department. The applicant should be prepared to provide feedback about his/her preceptor as well as the process they have just completed. Note: Candidates MUST pass each phase of the program before continuing. If the candidate is unable to successfully complete steps 3 or 4 in the process, he/she will wait 90 days before retrying. At the end of 90 days the candidate will be allowed to continue from the last successfully completed step. However, if the candidate is unable to complete the requirements the second time, the candidate will wait six (6) months before re-applying and will be required to repeat the entire process. Revision Date 11/01/2012 29 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PARAMEDIC III PROMOTIONAL REQUIREMENTS CG 15 Page 30 TOC Montgomery County Hospital District acknowledges the value of In-Charge Paramedics who consistently meet or exceed department standards in their daily performance of patient care as well as performing other duties as asked or assigned. Therefore, a Paramedic III position has been created to allow for recognition as well as the professional growth and development of these employees. Requirements for consideration in this promotional process are as follows: • • • • • • • • • • • • • • • GED or High School Graduate required, A.A.S. preferred Current EMT-Paramedic certification required, Licensure preferred verified on DSHS website Candidate should be in good standing with the Clinical Department and Operations Minimum of 4 years as an In-Charge Paramedic (two (2) years may be as the lead medic for another 9-1-1 service however two (2) years SHOULD be at MCHD ACLS-I Required BTLS-I Required PALS-I Required Texas Department of State Health Services EMS-I preferred Continual demonstration of exceptional decision making skills, appropriate patient assessment and development of a patient care plan Should demonstrate knowledge of MCHD Policies & Procedures and recognize their importance in decision making Continual demonstration of Leadership and mentoring skills Displays ability to work with first responder agencies and other public safety organizations within Montgomery County Displays ability to multi-task and delegate tasks appropriately Should possess good communication skills including, writing and verbal Should maintain professional appearance and demeanor at all times Once a candidate meets all of these requirements he/she should write a letter to the Clinical Department that includes: • What skills would you want your ideal P-III to have • What qualities make a good P-III • Why he/she wants to become a P-III • Brief summary of past experiences that might qualify applicants for the position (may be non-EMS related) • Strengths and weaknesses of the applicant and how they may impact ability to perform at this level Revision Date 11/01/2012 30 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PARAMEDIC III PROMOTIONAL REQUIREMENTS CG 15 Page 31 TOC When the Clinical Department receives a letter of intent from a P-III candidate the following should occur: • All Applicants should be in good standing with all MCHD departments • Verify status of DSHS certification on DSHS website • Evaluation of documentation compliance • Verfiy attendance of all mandatory C.E. Classes • Evaluation forms will be forwared to First Responder agencies within Montgomery County for feedback (completed by P-III) • Involvement in community activities Note: this is solely EMS related. Coachign your child’s soccer team, participation in local community activities • Analyze transport and refusal ratios in relation to peers • Review field and station evaluation scores as documented by Supervisors • Review past annual performance evaluations (Manager Only) • Applicants should have two (2) – three P-III’s assigned to ensure evaluation forms are completed and returned to the committee in a timely manner When the evaluations are completed and returned the Paramedic III Committee should meet to discuss and evaluate information for each applicant. The committee should then classify the applicants in numerical order. Applicants who have been classified will be offered the opportunity for the P-III promotional process as positions become available in numerical order assigned by the Paramedic III committee. These classifications will be recognized for one (1) year. After the applicant receives an offer for promotion the following should occur: • • • • A P-III should be assigned to evaluate the applicant. These evaluations may occur any time the candidate is at work and should include an inspection of the Medic Unit and/or the station. (Two (2) P-III’s may be assigned to a candidate to ensure completion in a timely manner). During this evaluation the candidate should assume the duties and responsibilities of a P-III including the performance of any procedures and/or medications that require a consult. VERBALIZE what treatment and/or procedure you have determined is appropriate for your patient/s. Your knowledge of the protocols as well as your thought process are being evaluated. Your preceptor should also be observing your skills of scene management, appropriate delegation of treatment and/or procedures when appropriate, as well as interaction the with the communications center, family members and any nonMCHD agency on the response. This process should continue until the preceptor has observed and evaluated the candidate on several responses with documentation forwarded to the P-III Committee and Clinical Department. The preceptor should review the outcomes of the evaluations after each call or when time is available during the shift. Revision Date 11/01/2012 31 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines • PARAMEDIC III PROMOTIONAL REQUIREMENTS CG 15 Page 32 TOC Supervisors may assist during your evaluation by performing unit and station evaluations and observing specific skills performed and forwarding documentation to the assigned preceptor and the Clinical Department. (The Supervisor should not inform the applicant that a station and unit inspections will be performed.) Upon completion of the evaluation process the applicant may be assigned to work the Squad and will be evaluated on the following: • • • • • • • Self motivation Review of equipment and medical supplies unique to the Squad Knowledge of territory Ability to key map and respond to a call without assistance from a partner Communications with Alarm during and after the response Scene Assessment and Management Appropriate medical/trauma assessment and treatment performed prior to the arrival of the medic unit. (Note) While the organization as a whole strives to allow each individual employee the flexibility of choosing a schedule or assignment, assignments may be made or adjusted as required to insure the best interest of the service are met. Upon completion of this phase the Paramedic III Committee will schedule an interview with the candidate. The interview committee should consist of the following members: • • • Two (2) – three (3)Employees currently authorized by the Medical Director at the Paramedic III scope of Practice Assistant Director EMS-Clinical Services Assistant Director EMS-Operations Within 7 business days of the interview the candidate should receive written notification of acceptance into the program or a refusal letter from the Paramedic III Committee. Candidates who are denied this promotional opportunity will meet with members of the Paramedic III committee to discuss a strategy plan and the applicant may re-apply in six (6) months. Revision Date 11/01/2012 32 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PARAMEDIC IV PROMOTIONAL REQUIREMENTS CG 16 Page 33 TOC Under development Revision Date 11/01/2012 33 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines TRANSFER TRUCK / SPECIAL EVENT AUTHORIZATION CG 17 Page 34 TOC Medical Authorization for Attendant Level Paramedics assigned to an MICU for Transfer Truck, Special Events and/or Standbys This policy establishes patient care activities for Special Events and/or standbys for employees currently authorized by the Medical Director as Paramedics and/or EMTIntermediates at the attendant level within the MCHD organization. General Information All Special Event and/or Standby units should have two- (2) attendant level Paramedics to be in service. An exception would be an experienced EMT-Intermediate in good standing with the organization. Approval for an EMT-Intermediate to work a special event unit with an attendant level Paramedic is at the discretion of the Assistant Director EMS-Clinical Services or his/her designee. One (1) employee should have a minimum of six- (6) month’s employment with MCHD. Optimally, both Attendants should be full time employees; however, a part-time employee; working the required number of hours to maintain part-time status and is in good standing in the organization may be approved to work the special event unit on a case-by-case request. The Supervisors and Alarm should be notified whenever a Special Event and/or Standby unit is placed in service with Attendant Level employees as well as the location of the standby. Controlled Substances should be obtained from the lock boxes outside the Supervisor’s office. The employee with the most seniority and/or Paramedic authorization should be responsible for signing the Controlled Substance sign-in log and maintaining security of the key. Units dedicated to any event usually do not transport patients from the site. When the crew encounters a patient, Alarm should be contacted for a new incident number and, if the patient requires transport, another unit should be sent to their location. The following interventions represent patient care that may be performed by Attendant Level Paramedics assigned to an MICU for Special Events and/or Standbys BEFORE Supervisor consult. • Patient assessment • Pulse oximetry • Oxygen administration • Use of oral adjuncts including oral and nasal airways, bag-valve mask device and oral suctioning. • Provision of CPR as defined by the American Heart Association • Vital signs • Bandaging and splinting including traction splinting • Spinal Motion Restriction • Manual techniques for airway provision, maintenance and support, relief of airway obstruction as prescribed by AHA • Control of external hemorrhage • Use of automatic CPR device* (Thumper) Revision Date 11/01/2012 34 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines • • • • • • • • • • • • • • • • • • • • • • TRANSFER TRUCK / SPECIAL EVENT AUTHORIZATION CG 17 Page 35 TOC Automatic external defibrillator* Emergency childbirth Blood Glucose assessment Aspirin administration NTG administration Nebulized Metered inhalers Vascular access Intraosseous infusion IV Fluid administration Administration of Nitrous Oxide Orotracheal intubation Use of PEEP Blood specimen collection MAST trousers Midazolam for Active Seizures, IM/IV/IO First round of Cardiac Medications via most appropriate route (additional cardiac medications require consult) Obtaining and interpreting ECG Obtaining and interpreting 12-Lead ECG Vagal maneuvers (Valsalva only) Defibrillation / Cardioversion External Cardiac Pacing Nebulized bronchodilation The following interventions Require Supervisor Consult • ALL Patient Refusals (each refusal SHOULD have their own incident number) • Additional Cardiac Medications • Nasogastric intubation/lavage • External jugular cannulation • Nasotracheal intubation • Chest decompression • Surgical airway • Rapid Sequence Intubation • Pericardiocentesis • Retavase Should Not be administered by the Special Event crew unless Supervisor is on scene with unit Revision Date 11/01/2012 35 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FIRST RESPONDER SCOPE OF PRACTICE CG 18 Page 36 TOC Current first responders shall provide pre-hospital care at the BLS level only. This includes those first responders who are currently certified as ALS providers. Exceptions: Woodlands Fire Department personnel: Medical control is extended to WFD personnel practicing within the boundaries of the Woodlands while on-duty. WFD personnel may function within the scope of practice of their certification and the policies of MCHD EMS. Off-Duty MCHD EMS Employees: Medical control is extended to off duty EMS personnel functioning within the boundaries of Montgomery County. An approved First responder (FR) may perform BLS skills as listed below under the following circumstances: • The FR is released by MCHD EMS at the FR level. • The FR carries a current Texas Department of State Health Services certification at the EMT, EMT-I, or EMT-P level. • A FR is an intern and is under the guidance of an approved preceptor who is present at all times while a skill is performed. • The procedure being performed is according to MCHD EMS protocols. While at the scene of an emergency, an approved First Responder is authorized to perform any of the following: • Evaluation of the sick and injured • Perform the following non-invasive diagnostic procedures: − Temperature − Blood pressure − Pulse − Respiratory rate • Render basic life support, rescue and first aid to patients with one or more of the following: − Medical Emergencies − Trauma Emergencies − Environmental Emergencies − Psychiatric Emergencies − Obstetrical Emergencies • Perform Cardiopulmonary Resuscitation. • Use the following adjunctive airway devices. − Oropharyngeal Airway − Nasopharyngeal Airway − Suction devices − Basic oxygen delivery devices − Manual ventilating devices • Use various extremity and body immobilization devices. • Optional Skills: − Use of Automatic External Defibrillator (AED) upon completion of an approved AED class. Revision Date 11/01/2012 36 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines ENCOUNTERING EMERGENCIES CG 19 Page 37 TOC The purpose of this policy is to provide employees with guidelines for taking action when encountering an emergency while on duty and responding to a call or hospital. MCHD EMS has a duty to act when confronted with any emergency scene encountered within its territory. The following guidelines should be followed if an employee encounters are emergency while “on the air.” • • Incidents with no injuries should be reported to Alarm if creating a hazard. Major accidents or incidents with obvious illnesses or injuries should be reported to Alarm. The crew should stop and assess, treat and/or transport as necessary. The following guidelines should be followed if an employee encounters an emergency while responding to a call or to a hospital: • • • • • Incidents with no injuries should be reported to Alarm if creating a hazard. Major accidents or incidents with obvious illnesses or injuries should be reported to Alarm. The dispatcher should determine whether the unit should proceed to the original call or be assigned to the new incident. If transporting a non-urgent/non-critical patient, stop, assess the scene for injuries. At least one crew-member should stay with the patient being transported. If transporting an urgent/critical patient, contact Alarm and advise of the incident, but do not stop and assess. The following guidelines should be followed if an employee encounters an emergency in a neighboring service area: • • • • Notify Alarm of the incident and have the appropriate service respond. Stop and render aid. Await the arrival of the appropriate unit. MCHD EMS will transport patients if asked to do so by representatives of the agency assigned to that territory. All patient care provided by MCHD EMS personnel should adhere to the Clinical Guidelines and Guidelines provided by the MCHD Medical Director. Revision Date 11/01/2012 37 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines POTIENTALLY VIOLENT SCENES AND STAGING CG 20 Page 38 TOC The purpose of this policy is to establish guidelines to be followed by MCHD EMS personnel when responding to any incident that may place crewmembers in a potentially dangerous situation. Staging Staging refers to the positioning of the medic unit in a secure location until Law Enforcement has cleared the scene or the crew has assured that the scene is safe. Alarm may advise a medic unit to stage when it receives information that is indicative of a hazardous or dangerous situation. If Alarm advises a medic unit to stage, the unit’s crewmembers should position the unit at a safe distance from the scene. Medic units should be staged by Alarm in the following situations: • • • • • • • Assaults/sexual assaults; Any scene with known or possible firearm involvement; Known/suspected GSW or stabbing; Domestic disturbances; When Violent/Psychiatric/Suicidal patients are involved; When advised to stage by the sheriff’s department; and During other situations deemed dangerous by Alarm; Anytime that a crew is required to stage for law enforcement the response will be reduced to non-emergency. Self Defense Self-defense is the act or acts of an individual used to defend or protect him/herself from harm. MCHD EMS personnel can defend themselves against a combative patient but can only use the amount of force necessary to protect themselves. MCHD EMS personnel may take any action necessary, including the use of reasonable force, to protect themselves or others against a combative person. However, MCHD EMS personnel are not authorized to seek revenge in a punishing manner. MCHD EMS personnel confronted by a combative individual at the scene of an incident should make every effort to avoid confrontation by departing the scene and making an immediate request for law enforcement assistance. If efforts to avoid confrontation prove unsuccessful and personal injury to MCHD EMS personnel appears imminent, crewmembers on the scene may have to use reasonable force to address the situation. Revision Date 11/01/2012 38 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines POTIENTALLY VIOLENT SCENES AND STAGING CG 20 Page 39 TOC Crewmembers should inform Law Enforcement and the Field Supervisor of the situation as soon as possible. Reasonable Force “Reasonable Force” is the amount of force necessary to keep an individual from causing injury to herself/himself or others. Stated differently, the amount of force used by MCHD EMS personnel cannot exceed the force being used against MCHD EMS personnel. MCHD EMS personnel should only use reasonable force after efforts to avoid confrontation have failed. Patient Restraint Restraining is an act of force used to prevent someone from doing something, particularly something that may be physically harmful, or to keep him under control. EMS personnel should consider restraining a patient when careful assessment of the patient reveals that the individual, due to a medical or psychiatric condition, is a danger to him/herself or others. MCHD EMS personnel should adhere to the following guidelines when restraining patients: • • • • • • • The objective should be to place whatever reasonable restraints are necessary on the patient as quickly as possible, with the least amount of discomfort to the patient, and with the least amount of force. Restraint should be individualized and afford as much dignity to the patient as the situation allows. Any restraint should be humanely and professionally administered. The method of restraint should be the least restrictive means necessary for the protection of the patient and others. When encountering a “pre-violent” patient, keep him/her under constant observation and be alert for signs of escalating anxiety. Do not take personal chances; never attempt to subdue or physically restrain a person if you are alone. Never hesitate to back off and obtain adequate assistance. Such a time-out may promote de-escalation of anxiety. Remember that the restrained patient has no way of exiting the unit in an emergency and is therefore totally dependent on the crew for his/her welfare. The use of restraints should be carefully documented. Such documentation should include the reason for and means of restraint and the periodic assessment of the restrained patient. All patient contacts that fall under this policy require MCHD EMS personnel to contact or consult a Supervisor. Revision Date 11/01/2012 39 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines COORDINATION WITH LAW ENFORCEMENT CG 21 Page 40 TOC This policy establishes guidelines to be followed by employees responding to or dealing with any suspected/known criminal activity and/or functioning in or around a crime scene. General Information In order to effectively serve the public, it is necessary for MCHD EMS personnel to maintain a positive working relationship with all of the Law Enforcement agencies within Montgomery County. Patient Interrogation: Patient care shall always remain the primary concern of MCHD EMS personnel during any joint EMS/Law Enforcement operation. Law Enforcement officers conducting an investigation are permitted to detain and question patients at the scene as long as such questioning does not interfere with the treatment of urgent/critically injured patients or jeopardizes the patient’s health. Patients in Custody / Prisoner Transport Any patient that is in custody or “under arrest” shall receive the same quality of care expected to be given to any other patient. If a patient in custody requires transport or if the arresting officer is requests transport, MCHD EMS personnel shall transport the patient to the most appropriate facility. If the arresting officer does not feel that the patient requires transport, and this conflicts with the opinion of MCHD EMS personnel, crewmembers shall exercise due diligence to convince the arresting officer of the necessity to transport the patient to a medical facility. At a minimum, the arresting officer shall follow the patient to the hospital and have the patient handcuffed during transport. If at all possible, the patient should be cuffed in front or with hands at his or her side to facilitate vascular access. If crewmembers become uncomfortable riding alone with the patient, they may request that an officer accompany them in the back of the ambulance. Any questions should be directed to the on-duty Supervisor. Patients / prisoners should never be handcuffed to the stretcher or directly to the ambulance. Belligerent and Violent Patients If not already enroute or on location, Law Enforcement should be called to assist with the patient. Unless instructed to do so by Law Enforcement or the patient is an obvious threat to him/herself or employees, belligerent or violent patients should not be restrained. Revision Date 11/01/2012 40 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines COORDINATION WITH LAW ENFORCEMENT CG 21 Page 41 TOC When the belligerent or violent patient requires transport for any medical, mental, or safety reason, but refuses to be transported, MCHD EMS personnel should that Law Enforcement assume responsibility and place the patient in protective custody. Transportation of the patient shall then occur as with any patient in custody. A belligerent patient may refuse treatment and transport, and then refuse to sign the release. MCHD EMS personnel should assure that the patient is competent and not a threat to him/herself or anyone else prior to letting the patient refuse care. Law Enforcement should called to the scene and asked to sign as a witness on the release form. Intoxicated/Under the Influence Patients who present to employees “under the influence” and require medical care are entitled to the same quality of care as given to any other patient. Several disorders, including hypoglycemia, epilepsy, and even some psychological disorders present as intoxication. Therefore, employees should not dismiss a patient as “under the influence” unless the patient confirms that the nature of the illness is the result of a moderate consumption of alcohol or other mind-altering substances. Any patient that presents with signs of intoxication and does not require medical care shall be referred to Law Enforcement. If Law Enforcement officers are not on location, employees should stand-by on location until their arrival. Preserving Evidence / Crime Scene Management Upon arriving at the scene of a suspected or known crime prior to Law Enforcement, employees should assure that the scene is safe. If employees suspect criminal activity, crews should pay particular attention to the environment and the patient. While the importance of preserving evidence should be kept in mind, it is emphasized that this should be secondary to patient care and resuscitative measures. In an effort to keep disruptions of the crime scene to a minimum, crewmembers should use the same pathway into and out of the crime scene. Unless necessary for crew safety or patient care, nothing in the “crime scene” should be touched or moved. Injured Patient When patient care necessitates moving the patient, evidence or objects, crew members should be prepared to make written notes of what was moved, the location of object prior to moving, who moved object, and why the object was moved. The following guidelines should be adhered to when moving evidence or objects at a suspected or known crime scene. Revision Date 11/01/2012 41 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines • • • • • • • • COORDINATION WITH LAW ENFORCEMENT CG 21 Page 42 TOC When evidence is moved, crews should always use gloved hands. Weapons should be picked up using rough surfaces such as a handle. Tweezers and hemostats can also be used to pick up evidence. All evidence should be placed in a paper bag for preservation. Avoid cutting or tearing areas of a patient’s clothing that might contain markings from entrance or exit wounds. The patient’s clothes should be cut along seams to prevent disruption of potential evidence. Place any clothing or other patient belongings into a paper bag to give to the investigating officer. Evidence can be very inconspicuous; crewmembers should be observant and cautious not to disturb any fingerprints, footprints, or other evidence. If immediate transport is not necessary, crews should remain on scene until the arrival of Law Enforcement to preserve scene integrity. All non-essential personnel and onlookers should not be allowed into the crime scene area. Dead On Scene (DOS) If the patient is obviously dead and the death appears to be due to other than natural causes, the following procedures are to be followed: • • • • • Do not touch or move the body. Immediately request the appropriate Law Enforcement agency, if not already on the scene. Do not touch or move any weapons, medication containers, suicide notes or any other items that may be pertinent to the incident investigation. Avoid touching doors, windows, light switches, etc. Scene telephones should only be used after clearance by a Senior Law Enforcement officer. Suicides Law Enforcement should be notified of all suicides or attempted suicides. Upon arriving at the scene of a suicide do not remove the body unless it is absolutely necessary. When a body should be moved, a sketch shall be made to help in the investigation of the suicide. If the suicide was due to hanging and patient assessment or treatment makes it necessary to cut the patient down, do not cut or untie any knots. If it is determined that the patient is dead, leave the noose intact about the neck. If the patient is alive and immediate transport is necessary before Law Enforcement arrives, take any suicide notes or evidence necessary to preserve your findings and the crime scene. As soon as possible have Law Enforcement notified of the transport destination. If Law Enforcement is on the scene, leave the suicide note and any other evidence with the Law Enforcement officer(s). Revision Date 11/01/2012 42 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines COORDINATION WITH LAW ENFORCEMENT CG 21 Page 43 TOC Narcotics Unless a patient’s condition warrants immediate transport, crews should remain on scene and await the arrival of Law Enforcement when an incident involves narcotics or other controlled substances. • • • When a patient’s condition warrants immediate transport, if possible, crewmembers should take a sample of the narcotic as the doctor will need it for analysis. Crewmembers should never handle an unknown substance with their bare hands as several street drugs can be absorbed through the skin. If Law Enforcement is not on location when the patient is transported, they should be notified as soon as possible as to where the substance will be, how much was transported, and with whom it will be left at the hospital. If at all possible, crewmembers should remain at the hospital with the evidence until the arrival of Law Enforcement. Requesting Law Enforcement Assistance • Employees should call for Law Enforcement assistance anytime a crewmember feels threatened or assistance is needed in controlling a scene or combative patient. Communications shall Automatically Notify Law Enforcement when any of the Following Occurs: • • • • • • • • • • • Assaults/Sexual assaults; Domestic disputes/disturbances; Animal bites; Motor Vehicle Accidents (MVA’s); Overdoses; Shootings; Stabbings; Attempted suicides; Suspected/Known DOA’s; Suspected child and/or elderly abuse; or Unknown type emergencies. When crews arrive on the scene of an incident and feel an immediate threat to their own safety, they should immediately withdraw from the scene to a secure location and notify Communications. Jail Responses When responding to incidents at any detention facility within Montgomery County, employees should adhere to the following guidelines: Revision Date 11/01/2012 43 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines • • • • • • COORDINATION WITH LAW ENFORCEMENT CG 21 Page 44 TOC The communications center should only dispatch the medic unit unless the information received suggests that more personnel may be required; Equipment brought into the detention facility should never be left unattended in the prisoner area; Never proceed through the detention facility unescorted, always have a Law Enforcement escort both into and out of the facility; Personnel should never be left unattended at a detention facility; If the prisoner is transported, a Law Enforcement officer should accompany the prisoner. All patients who are in custody should be handcuffed and accompanied by a Law Enforcement officer. If possible, patients should be cuffed with their arms to their sides to facilitate vascular access. A Law Enforcement officer should accompany the patient to the hospital. At a minimum, a Law Enforcement officer shall follow the medic unit to the transport destination. If at anytime the crew becomes uncomfortable riding alone with the patient, request that a Law Enforcement officer accompany the patient/prisoner in the back of the ambulance. Any questions should be directed to an on-duty Supervisor; and Patients/prisoners should never be handcuffed to the stretcher or directly to the ambulance. Revision Date 11/01/2012 44 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines REQUESTS FOR ASSISTANCE CG 22 Page 45 TOC This policy establishes guidelines to be followed by MCHD EMS personnel needing to request additional assistance while on the scene of an incident. General Information MCHD EMS crews have the authority to call for additional assistance in any situation or condition in which they do not have the available resources or ability to manage the scene. Additional assistance may be requested for any one or more of the following: • • • • • • • Medic Units; Medical Personnel; Helicopter Transport; Fire apparatus; Rescue equipment; Law Enforcement; or Specialized Services (for example, Pastoral, CPS, or APS services). Upon arriving on location of any incident, MCHD EMS personnel need to determine as quickly as possible if any additional equipment, supplies, and/or manpower will be required. Crews shall notify Alarm of their specific needs. A crew requesting additional assistance should provide alarm with the following information: • • • • Type of assistance needed; Reason for request; Exact location; and Any special conditions or circumstances. Revision Date 11/01/2012 45 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines • • • • • • • • TRANSPORTING PATIENT VALUABLES CG 23 Page 46 TOC It shall be the goal of employees to ensure that all of a patient’s personal belongings stay with the patient and arrive at the destination with the patient. If articles are unintentionally left in the ambulance they should be returned as soon as possible. MCHD EMS discourages the unnecessary handling of patient belongings. It is the responsibility of the field crew to ensure that all patient belongings are appropriately handled. Employees should document all personal belongings of the patient that are handled by employees during patient contact. Employees should make an inventory listing of the items on the computerized patient report in the “Personal Effects” field and obtain a signature for disposition of the items. If contact with patient valuables (purse, wallet, etc.) is necessary, it should be done in the presence of at least one witness not employed by the MCHD, such as a law enforcement officer or other official. If removal of patient valuables is justified by a need to reduce possible injury or for a medical procedure, removal should be witnessed by a law enforcement officer or other official and placed in a safe location. In all instances, the handling of valuables (and their description) should be clearly documented on the ambulance run form and the witness to the handling of the items should be identified. Employees should consult local hospital policies regarding valuables because some hospitals may require that all patient valuables be turned over to hospital security, or other authorized personnel. Revision Date 11/01/2012 46 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines ORGAN DONOR PROCUREMENT - LIFEGIFT CG 24 Page 47 TOC Donor Referral In the event MCHD EMS elects to withhold resuscitation, or terminate resuscitation, the following procedure should occur. This shall also be applicable in situations in which a crew encounters a death on scene and those in which a patient delivered to an Emergency Department expires such that the crew has knowledge of the patient’s demise The family members should be notified of the lack of resuscitation efforts (if they are present). Upon completion of the call and departure from the scene, the In-Charge Paramedic should call Life Gift at 800.633.6562 and give them the following information: • The location of the incident • Patient Information – Name, Age, Sex, Race • Mechanism of Injury / History of Present Illness • Past Medical History • Next of Kin or responsible party – name and phone number • Any other relevant information Give Life Gift your contact information (use 936.441.MCHD for your call back). It is recommended that you do not notify the family about the donor referral. There is no situation where donor referral should not be done. Life Gift should provide follow up by phone (within 24 hours) and by letter (within 30 days). Revision Date 11/01/2012 47 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PATIENT CONSENT CG 25 Page 48 TOC This policy establishes guidelines for obtaining patient consent for emergency care. General Information MCHD EMS PERSONNEL SHALL NOT REFUSE TRANSPORTATION TO ANY PATIENT, UNDER ANY CIRCUMSTANCES. Patient Consent for Service Texas Health and Safety Code § 773.008 of the provides that consent for emergency care of an individual is not required if: Consent for emergency care of an individual is not required if: (1) the individual is: (A) unable to communicate because of an injury, accident, or illness or is unconscious; and (B) suffering from what reasonably appears to be a life-threatening injury or illness; (2) a court of record orders the treatment of an individual who is in an imminent emergency to prevent the individual's serious bodily injury or loss of life; or (3) the individual is a minor who is suffering from what reasonably appears to be a lifethreatening injury or illness and whose parents, managing or possessory conservator, or guardian is not present. Consent to Treatment of Child by Non-Parent Texas Family Code § 32.001 of the provides that the following persons may consent to medical treatment of a child when the person having the right to consent as otherwise provided by law cannot be contacted and that person has not given actual notice to the contrary: § 32.001. Consent by Non-Parent (a) The following persons may consent to medical, dental, psychological, and surgical treatment of a child when the person having the right to consent as otherwise provided by law cannot be contacted and that person has not given actual notice to the contrary: (1) a grandparent of the child; (2) an adult brother or sister of the child; (3) an adult aunt or uncle of the child; Revision Date 11/01/2012 48 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PATIENT CONSENT CG 25 Page 49 TOC (4) an educational institution in which the child is enrolled that has received written authorization to consent from a person having the right to consent; (5) an adult who has actual care, control, and possession of the child and has written authorization to consent from a person having the right to consent; (6) a court having jurisdiction over a suit affecting the parent-child relationship of which the child is the subject; (7) an adult responsible for the actual care, control, and possession of a child under the jurisdiction of a juvenile court or committed by a juvenile court to the care of an agency of the state or county; or (8) a peace officer who has lawfully taken custody of a minor, if the peace officer has reasonable grounds to believe the minor is in need of immediate medical treatment. (b) The Texas Youth Commission may consent to the medical, dental, psychological, and surgical treatment of a child committed to it under Title 3 when the person having the right to consent has been contacted and that person has not given actual notice to the contrary. (c) This section does not apply to consent for the immunization of a child. (d) A person who consents to the medical treatment of a minor under Subsection (a)(7) or (8) is immune from liability for damages resulting from the examination or treatment of the minor, except to the extent of the person's own acts of negligence. A physician or dentist licensed to practice in this state, or a hospital or medical facility at which a minor is treated is immune from liability for damages resulting from the examination or treatment of a minor under this section, except to the extent of the person's own acts of negligence. Consent to Treatment by Child Texas Family Code § 32.003 provides that a child may consent to medical treatment if the child: § 32.003. Consent to Treatment by Child (a) A child may consent to medical, dental, psychological, and surgical treatment for the child by a licensed physician or dentist if the child: (1) is on active duty with the armed services of the United States of America; (2) is: (A) 16 years of age or older and resides separate and apart from the child's parents, managing conservator, or guardian, with or without the consent of the parents, managing conservator, or guardian and regardless of the duration of the residence; and (B) managing the child's own financial affairs, regardless of the source of the income; Revision Date 11/01/2012 49 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PATIENT CONSENT CG 25 Page 50 TOC (3) consents to the diagnosis and treatment of an infectious, contagious, or communicable disease that is required by law or a rule to be reported by the licensed physician or dentist to a local health officer or the Texas Department of Health, including all diseases within the scope of Section 81.041, Health and Safety Code; (4) is unmarried and pregnant and consents to hospital, medical, or surgical treatment, other than abortion, related to the pregnancy; (5) consents to examination and treatment for drug or chemical addiction, drug or chemical dependency, or any other condition directly related to drug or chemical use; or (6) is unmarried, is the parent of a child, and has actual custody of his or her child and consents to medical, dental, psychological, or surgical treatment for the child. (b) Consent by a child to medical, dental, psychological, and surgical treatment under this section is not subject to disaffirmance because of minority. (c) Consent of the parents, managing conservator, or guardian of a child is not necessary in order to authorize hospital, medical, surgical, or dental care under this section. (d) A licensed physician, dentist, or psychologist may, with or without the consent of a child who is a patient, advise the parents, managing conservator, or guardian of the child of the treatment given to or needed by the child. (e) A physician, dentist, psychologist, hospital, or medical facility is not liable for the examination and treatment of a child under this section except for the provider's or the facility's own acts of negligence. (f) A physician, dentist, psychologist, hospital, or medical facility may rely on the written statement of the child containing the grounds on which the child has capacity to consent to the child's medical treatment. Patient Refusal of Service All conscious, self-sufficient persons retain the right to refuse service. MCHD EMS personnel shall attempt to have the patient (if minor: parent, guardian, etc.) read and sign the statement of refusal of care and transport. Such statement is located on the patient report. MCHD EMS personnel shall record in their narrative report the refusal and their statements concerning information provided any attempts at medical aid, and conditions under which the signature was obtained. MCHD EMS personnel are charged with the responsibility of assuring that patient are informed of the reasonable consequences of treatment and refusals. Bystanders shall witness signatures for such informed refusal, if possible. If there are no bystanders then signatures for such informed refusal shall be witnessed by another member of the Department, a Fire or Law Enforcement officer, or other Medical Personnel present at the scene. Revision Date 11/01/2012 50 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PATIENT CONSENT CG 25 Page 51 TOC Refusal of Signature If an individual refuses to sign the refusal of care statement, MCHD EMS personnel should have the refusal witnessed by a third party, preferably someone not employed by MCHD EMS. A statement regarding the circumstances of individual’s refusal to sign the statement should appear on the patient report accompanied by signature of a witness, if possible. Refusal of Specific Treatment Any treatment refused by the patient and ordered by a physician (Standing order or verbal) shall be reported to the medical control physician prior to acceptance of the refusal signature. MCHD EMS personnel should explain to the patient complications that may arise from such refusal. MCHD EMS personnel should record such refusal of specific treatment(s) and the complications about which the patient was informed. The In-Charge Paramedic shall attend to the patient during transport. Revision Date 11/01/2012 51 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PATIENT REFUSAL CG 26 Page 52 TOC The purpose of this policy is to provide EMS personnel with clear rules for managing situations in which the patient or the patient’s representative declines or refuses care or transportation by EMS. If a patient (or legal patient representative) requests evaluation, treatment, and/or transport from MCHD EMS, they will be actively encouraged to seek medical care from a physician regardless of the nature of that request. Under no circumstances will MCHD EMS personnel refuse or deny treatment or EMS transportation to any patient (or legal patient representative) who requests medical assistance, through any means, from the agency MCHD EMS personnel shall not discourage any patient (or legal patient representative) from seeking medical care from a physician or from accepting EMS transport to a hospital. All Patient Refusals involving individuals exhibiting deficits in mental capacities, or with question as to possessing legal custody of themselves, should go through the current Medical Control system in place (i.e. EMS Supervisor on duty). All patients should have the following assessment and documentation regardless as to whether the patient is refusing transport. If the patient meets the criteria below and refuses to allow part or parts of the patient assessment, the EMS provider shall comply with the patient’s request unless otherwise directed by Medical Control or law enforcement. The patient should then read and sign the Patient Refusal/Non-Transport statement documenting the fact that he was offered specific treatment and refused to allow that treatment. If any information that is not available to the medic on-scene, then the narrative should reflect that in the documentation. A patient has to meet certain criteria prior to accepting a refusal of care. The patient should be able to advise the following information and, therefore, be considered competent: 1. His/her own name 2. Where he/she is 3. What day of the week it is OR what month and year it is 4. What happened 5. Patient is without neurological deficit. 6. Patient history does not include recent substance abuse, or alcohol ingestion If the above criteria are not met, EMS should reject any acceptance of a patient refusal unless approval is obtained via consult. There are specific categories of patients that are inherently difficult with which to deal. The following is a guideline to assist in making the best decision for the patient. 1. Diabetic (hypoglycemic) patients unconscious on scene. If advanced care is rendered on scene and the patient becomes conscious and had an obtained blood glucose level of equal or greater than 80 mg/dl and does not wish to be transported, a Patient Refusal/Non-Transport statement should be filled out and signed. It is the responsibility of the on-scene medic to attempt to ensure that Revision Date 11/01/2012 52 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PATIENT REFUSAL CG 26 Page 53 TOC the patient is left in the company/custody of a family member, friend, or other individual that agrees to watch over that patient and is informed of the potential for recurrent hypoglycemia. That responsible party should also be aware of the need for medical evaluation/EMS activation should hypoglycemia return. 2. Suicidal/Threatens himself or others Make sure the scene is safe and that the crew is safe prior to entry. If the patient states that he attempted suicide, a patient refusal may not be accepted. If the patient refuses transport, law enforcement should be called to the scene. Law enforcement will determine whether to place the patient in protective custody. If the patient is not placed in protective custody, then Medical Control should be contacted. Law enforcement should not transport the patient who has ingested medications or has physical injuries. If law enforcement does transport the patient, the patient refusal should be signed by the highest-ranking law enforcement officer on-scene. 3. Patients in Law Enforcement Custody. Law Enforcement may mandate transport of a patient in custody regardless of the patient’s wishes. If the patient is in custody and is in need of transport, Law enforcement shall provide an officer who should either ride in the ambulance or follow the ambulance. If the patient determines that he/she wants out of the ambulance during transport and law enforcement is not available, the patient should be released from the ambulance at the safest possible time. 4. Incompetent Adult patients (mentally handicapped, mentally ill, Alzheimer’s, OBS, etc.) If the patient’s guardian is on scene with a Durable Power of Attorney, the patient may not refuse treatment or transport for himself. If the guardian is not oriented, Medical Control should be contacted. If the patient’s guardian cannot prove Durable Power of Attorney, Medical Control should be contacted. If the patient’s guardian is not present, Medical Control should attempt to contact the guardian. If the patient’s condition is urgent, the patient should be transported by standing order prior to guardian contact. 5. Emancipated Child patient Emancipation is defined as a minor (17 years or less) who is living apart from his legal guardian and who is not financially supported by his guardians.  Pregnant female  Person enlisted or commissioned in the U. S. Armed Forces  Person legally declared an adult by the courts  These patients shall be handled as adults. 6. Minor patient - Guardian present (Minor = less than 18 years of age) If oriented, the guardian should decide all patient care. If the patient is a refusal, the guardian should be given the instructions and sign the paperwork. If abuse of the patient is suspected, law enforcement should be notified by the communication’s center prior to leaving the scene. Law enforcement should Revision Date 11/01/2012 53 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PATIENT REFUSAL CG 26 Page 54 TOC make the final determination as to whether there is enough evidence to necessitate taking the child into protective custody and imposing medical care against the guardian’s wishes. 7. Minor patient - Guardian not present (Minor = less than 18 years of age) Minor patients who need to be transported, but are not urgent or critical, should be transported if the parent or guardian cannot be contacted after reasonable attempts have been made. The contact of a parent or guardian should be made through dispatch on a recorded line to serve as a record of consent or refusal. Documentation on all patient refusals requires: 1. Demographic and operational information as outlined in the Documentation Policy. 2. Assessment information including the patient’s/guardian’s mental status, physical assessment/general appearance, and vital signs. 3. The patient /guardian was advised of any complications that may arise from not seeking medical attention. 4. Proper signature from the patient. 5. Medical Control personnel involved if Medical Control is contacted. No Patient is defined as 1. No patient upon arrival of EMS. OR 2. False call, OR 3. Person or people on scene did not request an ambulance AND deny any physical complaint AND EMS personnel cannot visualize any injury or evidence of injury or illness AND the person on scene is competent to make such a decision. 4. If the patient called for the ambulance, the “No Patient” classification no longer applies. Revision Date 11/01/2012 54 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PATIENT REFUSAL CG 26 Page 55 TOC AMA REFUSAL OF CARE/TRANSPORT The purpose of this policy is to ensure that EMS personnel actively encourage a patient whose illness or injury is categorized below to accept treatment and transport. Any patient whose complaint or injury is categorized below should be an AMA refusal if the patient refuses treatment and/or transport. 1. ANYTIME ONE OF THE EMS CREWMEMBERS BELIEVES TRANSPORT IS INDICATED. 2. Cardio-respiratory signs and symptoms 3. Abdominal pain 4. Stabbing/Shooting 5. Overdose/Poisoning 6. Neurological • Seizure • Dysphasia • Hypoglycemic patients whose BG determination is < 60 mg/dl and shows signs and/or symptoms of neuro-deficit. A second BG should be obtained. 7. Pregnancy 8. Elderly (65 years or older) • Acute medical or surgical problem 9. Deceleration Injury, Near-Drowning, Electrocution 10. Mechanism of Injury • Fall from > 6 ft requires full spinal motion restriction regardless of complaint • Damage done to specific area in which the patient was sitting. • Death of a person in the same vehicle 11. Abuse • Although these patients may not always be transported, the proper law enforcement agency should be contacted prior to leaving the scene. 12. Ejection, Rollover, or lateral impact MVAs; or any MVA with significant vehicle damage Revision Date 11/01/2012 55 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines OXYGEN CG 27 Page 56 TOC MICU Oxygen should be maintained at the following levels to perform at peak effectiveness. Onboard (main) and Portable cylinders: On-Board Main O2 and all portable oxygen cylinders should have a minimum of 500psi. The ventilators should operate 20 minutes for every 400-psi (E cylinder) at maximum settings. Therefore, anything less than 500-psi does not provide optimum use. STATION SUPPLY Each station is responsible for contacting the current vendor for oxygen replacement used by the District for re-supply. Station supply should not fall below 1 main cylinder and 3 portable cylinders. Revision Date 11/01/2012 56 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines THIRD RIDERS CG 28 Page 57 TOC Third riders are considered to be approved probationary employees, students and/or observers that are assigned to a particular response vehicle. Only authorized persons will be allowed to ride on an EMS vehicle. The following guidelines shall apply: • • • • • • • • • Riders should be at least 18 years of age, or have expressed WRITTEN permission from the Operations Manager and a parental release signature on the Waiver of Liability form. The department scheduler and/or the Supervisor on duty should approve riders. Third riders shall be scheduled at least twenty-four hours in advance. All third riders should sign an Observer’s Release form prior to riding a shift. A new release form should be signed each time an individual rides Third riders should follow all requirements and rules prior to and while riding as an observer; It is the responsibility of all EMS personnel to assure that the rider has been approved to ride and an Observer’s Release form has been signed and is on file in the administrative office; It is the responsibility of all EMS personnel to note the personal appearance of each rider when she/he reports to the shift. If he/she does not meet the rules and regulations pertaining to dress, he/she should be advised of such by the EMS personnel and should not be permitted to ride until she/he has complied with the rules; Students and observers may be asked to leave at a moment's notice due to operations and training requirements. The department reserves the right to limit the number of shifts of any rider. Observers Observers are individuals who for some personal reason may desire the experience of prehospital care by observation. Frequently this is to gain a sense of EMS roles in the community and to understand the interaction of various agencies. The Assistant Director EMS-Operations or his/her designee shall approve citizen observers. Non-certified observers should not be involved in the patient care process, and are only allowed to observe the EMS personnel render care to the patient. Certified observers may participate in basic level patient care at the discretion and under the direct supervision of the In-Charge Paramedic. Be aware that representatives of the media or legal profession may observe events that they feel compelled to make public. These persons should be screened carefully and made aware of the terms of the Observer’s Release form before being allowed to ride. Observers are restricted to riding between the hours of 0700-2200. Observers are not allowed later than 2200 unless prior approval and arrangements have been approved by a Supervisor or higher management member. Revision Date 11/10/2005 57 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines THIRD RIDERS CG 28 Page 58 TOC NEOP Probationary members may participate in patient care to their certification level at the discretion, and under the direct supervision of the senior medical member on their assigned unit. Student Interns TDSHS approved courses wishing to have students ride on MCHD EMS units should have a signed affiliation agreement on file with the administrative office. Students from outside organizations should be scheduled in advance. Administration should ensure the presence of medical liability insurance and student qualifications. The student’s role is to interact in the patient care process by performing duties in accordance with the training program’s affiliation agreement and/or training objectives. The amount of involvement is to be determined by the senior medical staff member on the ambulance. Interns should perform the skills, as determined by the senior medical team leader, which fall within the practice for the certification the student is obtaining. Interns are "in training" and should not be left in the role of providing sole care for the patient except under extraordinary conditions. Interns should not treat patients until the In-Charge Paramedic approves all decisions concerning treatment. Acceptable Uniform EMS third riders are to dress neatly and conservatively at all times. The generic third rider uniform shall consist of: • • • • • Conservative-type shoes including black athletic type shoes or boots may be worn. It is recommended that sturdy shoes be worn. Sandals are prohibited. Black or navy EMS type pants should be worn. White uniform shirt or dress shirt should be worn. Blue jeans, shorts and t-shirts are prohibited Hair should be groomed. Cleanliness and appropriate physical hygiene are required at all times. Observers from approved first responder organizations will be allowed to wear their department uniform. Recognized EMS training programs may negotiate an acceptable, alternative uniform for EMS students. The Assistant Director EMS-Operations or his/her designee may approve specific apparel for special circumstances such as physicians, nurses, or media representatives. Revision Date 11/10/2005 58 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines THIRD RIDERS CG 28 Page 59 TOC Run Records Students and observers should not complete official run records for MCHD EMS. Probationary employees may complete records under the direct supervision of their preceptor. That person should co-sign the run record. All third riders’ identities should be documented on medical reporting forms. Conduct All EMS observers are to conduct themselves with proper decorum. Observers are to refrain from the following: • • • • • • • Use of alcoholic beverages 12 hours prior to and during the shift; Use of profane or abusive language; Use of excessive conversations which may interfere with radio communications while riding in unit; Making remarks, or voicing opinions to patients or family members, bystanders, police officers, fire personnel, or first responders in any manner, which would tend to provoke or degrade anyone or escalate tension/anxiety; Making known to any person not authorized, any information concerning the emergency call, patient information or outcome; Using information gained through EMS third rider program for personal gain; and Wearing on their clothing any article, sign or symbol that advertises any product, business or organization. Conclusion All third riders are subject to removal for any violation of the above rules and regulations. Crewmembers are responsible for the appearance and conduct of third riders. Should problems arise, it is recommended that a Supervisor be notified of the incident. Revision Date 11/10/2005 59 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines NON-EMERGENCY ASSIST CALLS CG 29 Page 60 TOC MCHD EMS will respond to all requests for assistance. In all cases, EMS personnel should attempt to aid the person requesting assistance. Non-emergency Assists MCHD EMS personnel should respond non-emergency to known non-emergency assist calls. Should there be doubt of the emergency nature of the request, personnel should respond emergency traffic. Chronic System Abuse Instances of repeated abuse of the EMS system by a member of the public should be reported to the on-duty Field Supervisor. Personnel should make every attempt to professionally educate the calling party of a more appropriate method of obtaining assistance. Repeated EMS system abuse, despite good faith efforts to intervene, should be referred to the Assistant Director EMS-Operations. If determined necessary, the Assistant Director EMS-Operations may refer the situation to the Medical Director. Malicious False Alarms In instances of malicious false alarms, EMS personnel should advise Alarm of the nature of the event. Law enforcement assistance should be requested if the calling party can be identified. MCHD EMS personnel should not confront the alleged calling party. Revision Date 11/10/2005 60 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CONFIDENTIALITY CG 30 Page 61 TOC Healthcare professionals have an important ethical and legal duty to guard and respect the confidential nature of the information conveyed during patient contact. All personnel implicitly promise to preserve patient confidentiality. Under the Tex. Health § Safety Code Ann. § 773.091(g), the following items are not considered confidential information and may be disclosed: • • • • • • Information regarding the presence, nature of injury or Illness Age Sex Occupation City of residence of a patient Confidentiality is not absolute. Confidential patient information may be disclosed when patients or their legal guardians agree to the disclosure, when mandated by law, or when there exist compelling or overriding ground for the disclosure, such as prevention of substantial harm to identifiable other persons. See Tex. Health & Safety Code Ann. § 773.091-095. Disclosure of confidential patient information is a serious transgression, and in some cases is considered a criminal offense. Employees that violate patient confidentiality should be called upon to justify their actions and may be subject to disciplinary action. Employees may be questioned about past responses by law enforcement, attorneys, insurance agencies, or other agencies. When this occurs, those persons should be directed to a Supervisor or the custodian of records. Patient Care Reports are confidential and can generally only be released by a subpoena. Revision Date 11/10/2005 61 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines OOH DNR AND DEATH ON SCENE CG 31 Page 62 TOC Out of Hospital Do Not Resuscitate (DNR) /Dead on Scene (DOS) Withholding, Terminating and Limiting Resuscitation This protocol shall provide the guidelines, standards and orders for managing situations involving the withholding, termination or limitation of resuscitative efforts in the terminally ill or fatally injured patient. This protocol addresses the following issues: • Apparently non-viable cardiac arrest cases (dead on scene) • Do not attempt resuscitation requests • Directive to physicians, Living Will directives or other directives which limit care to a terminally ill patient. Apparently Non-Viable Cardiac Arrest (Dead On Scene) The criteria for this component of the protocol is a pulseless and apneic patient in whom there is some question as to whether to initiate or continue resuscitative measures. MCHD EMS personnel are authorized to withhold or discontinue resuscitative measures in cases of: • Multi-patient incidents as described in the Multi-patient/Triage protocol • Decapitation • Decomposition • Rigor mortis (in the non-hypothermic patient) • Dependent lividity • Incineration • Visible trauma to the head or chest that is clearly incompatible with life • Valid Do Not Attempt Resuscitation directives as described in this protocol. When any patient meets the above criteria, access to the scene should be limited as much as possible with special attention to disturb the scene as little as possible. Every effort should be made to provide support for the family, friend, survivors as well as any witness to the event. A directive to withhold resuscitative measures shall not prevent EMS from providing appropriate emergency care to ease suffering such as oxygen administration, airway suctioning, authorized analgesia, and palliative care. State of Texas Out-of-Hospital Do-Not-Resuscitate Orders: The individual executing the OOH DNR agrees to have ALL of the following procedures withheld: • • • • Cardiopulmonary resuscitation Advanced airway management Artificial ventilation Transcutaneous pacing Revision Date 11/10/2005 62 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines • OOH DNR AND DEATH ON SCENE CG 31 Page 63 TOC Other life-sustaining treatment specified by Texas Board of Health. Palliative Care The provision of palliative (comfort) care and pain management is acceptable if the patient presents with a pulse and spontaneous respirations. Examples of palliative care include: • • • • • Oxygen therapy Suction IV Therapy Hemorrhage control Pain management To withhold resuscitation in the patient who becomes pulseless or apneic the following criteria SHOULD be met: • An official colored TDSHS OOR DNR identification bracelet or necklace is being worn by the patient OR • An official or photocopied TDSHS OOH DNR order is presented upon patient contact with all necessary patient information, signatures and boxes completed and present on the form. (SB 1260 changes this section to read “photocopy or other complete facsimile of the original written out-of-hospital DNR order executed under this subchapter may be used for any purpose which the original written order may be used under this subchapter.") OR • The patient’s private physician is either on-scene or via phone directs the provider to withhold any resuscitative efforts. The Texas DNR form is not to be honored and full resuscitative efforts, including BLS and ACLS are to be initiated, if any of the following conditions exist: The Patient: • Destroys the form and removes the identification device OR • Directs someone in their presence to destroy the form and remove the identification device OR • Communicates to the responding health care professionals or attending physician that it is his/her intent to revoke the order AND • Notifies the attending physician (if not present) that the order has been revoked. The Person who executed the order: • Destroys the form and removes the identification device OR • Directs someone in their presence to destroy the form and remove the identification device OR • Notifies the attending physician (if not present) that the order has been revoked. The attending physician: (or his/her designee) • If present at the time of revocation, records in the patient’s medical record the time, date and place of the revocation OR Revision Date 11/10/2005 63 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines OOH DNR AND DEATH ON SCENE CG 31 Page 64 TOC • If not present, records the time, date and place that the physician received notice of the revocation AND • Enters the word “VOID” on each page of the copy of the order in the person’s medical record. In addition to the above, the Texas DNR order is not to be honored if: • The patient is known to be pregnant • Unusual or suspicious circumstances are involved (suspected homicide or suicide). • Suspected criminal activity involving the patient. If Any of These Reasons for Revocation Are Met the Provider Should: • Initiate full resuscitative efforts. • Record the time, date and place of the revocation for DNR order revocation incident reporting to the Texas Department of State Health Services by the MCHD EMS Clinical Department. Note: Senate bill 1260 provides for the consolidation of all chapters related to Out-ofHospital DNR orders and advanced directives. These changes became effective September 1, 1999. • The person initiating a DNR does not have to be diagnosed with a terminal condition. • The document specifies the treatment rather than the procedures a person or legally authorized representative directs health care providers in an out-of-hospital setting not to initiate or continue. • The out-of-hospital setting as a location in which health care professionals are called for assistance is expanded to include hospital outpatient or emergency departments and physicians offices. • Requires the form to include certain physicians, a separate section for execution of the document by at least one, rather than two, qualified relatives and a statement that allows certain persons to make certain decisions (medical power of attorney). • OUT-of- STATE DNR orders are acceptable if there is no reason to question the authenticity of the order or device. All other cases should require authorization from field medical control or an on-line medical control physician. In ALL DNAR cases, the EMS crew should be completely confident in the authenticity of the documentation or device and in the patient's identification. If there is any doubt about the validity of the paperwork involved, always begin patient care. The on-duty Supervisor should determine whether to continue or terminate care. Resuscitation efforts may not be withheld from a person known by the health care professional to be pregnant. Documentation requirements for out of hospital DNAR: 1. Assessment of patient’s physical condition. Revision Date 11/10/2005 64 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines OOH DNR AND DEATH ON SCENE CG 31 Page 65 TOC 2. Type of device used to confirm DNAR status including patient identification number. 3. Any problems related to the implementation of the DNAR order. 4. Patient’s attending physician. 5. Full name, address, telephone number and relationship to patient of any witnesses used to identify the patient. 6. If the patient is transported the original DNAR order should be kept with the patient. 7. If the patient is not transported the original DNAR order should be left with the concerned parties or health care facility. Should the patient expire prior to the initiation of transport by EMS, the EMS crew shall: 1. Discontinue all medical care. 2. Prepare the body for viewing by the family and/or friends. 3. Allow the family/friends to view the body as they wish. Answer any questions regarding the patient’s clinical status upon your arrival and your actions, to the best of your ability. 4. Notify field Medical Control of the situation. 5. Notify, via the Communications Center, the appropriate law enforcement agency of an out-of-hospital death. 6. Complete all appropriate documentation. 7. Release the scene to law enforcement upon their arrival, providing them with a copy of the documentation. If a patient who is under a valid DNAR directive becomes pulseless and apneic during transport, the EMS crew shall: 1. Note the time the patient became pulseless and apneic. 2. Continue any care that is in progress at that point (e.g., oxygen administration, etc.). 3. DO NOT initiate any additional medical care. 4. Continue transport, in non-emergency traffic mode, to the destination facility. Revision Date 11/10/2005 65 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines OOH DNR AND DEATH ON SCENE CG 31 Page 66 TOC 5. Upon arrival at the destination facility, release the patient to the appropriate health care professional. Notify the receiving health care professionals that the patient became pulseless and apneic during transport and that, as per the patient’s binding directive, EMS did not treat the cardiac arrest. 6. Complete all appropriate documentation and leave copies with the receiving facility. Limitations of Care Competent adult patients have the right to select the care they receive from health care professionals. This right extends to emergency situations, the out-of-hospital care arena and even to resuscitation and end-of-life cases. This right may be exercised verbally by a competent adult patient (as described and defined in the Consent and Refusal policy). This right may also be exercised by written directive, executed by a patient when s/he was competent, even if that patient is no longer competent to consent to or refuse care. Last, selection and limitation of healthcare options and procedures may be exercised by a duly authorized representative of the patient (family member or representative empowered to do so by a Durable Power of Attorney) in cases where the patient is incompetent or unable to communicate their wishes. A directive to withhold or limit resuscitative measures shall not prevent EMS from providing appropriate emergency care to ameliorate suffering, such as oxygen administration, airway suctioning, or authorized analgesia. Should EMS personnel encounter a patient with an apparent terminal condition or in whom there is reason to believe the patient and/or family may wish to limit the care administered to the patient by EMS, the EMS personnel shall: 1. Determine the presence or absence of any written or verbal directives pertaining to limitations of care. If there is a written directive, review it carefully and clarify any unclear components with the patient and/or patient’s authorized representative. 2. Discuss the treatment options available to the patient from EMS with either the patient (if competent and able to communicate) or the patient’s authorized representative. 3. Clarify the interventions to which the patient (or representative) does and does not consent, prior to initiating transport. 4. Comply with the patient’s limitations and/or directives. If there is any doubt or concern about the validity or appropriateness of a directive to limit or withhold care, contact field medical control immediately. 5. Document the directive(s), either written or verbal, received from the patient or representative on the EMS chart. Revision Date 11/10/2005 66 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines Revision Date 11/10/2005 OOH DNR AND DEATH ON SCENE CG 31 Page 67 TOC 67 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines Revision Date 11/10/2005 OOH DNR AND DEATH ON SCENE CG 31 Page 68 TOC 68 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DESTINATION DETERMINATION CG 32 Page 69 TOC APPROVED TRANSPORT FACILITIES Personnel should consider the needs and desires of the patient as the primary factor in selecting a destination. They should take into consideration a facilities resources and capabilities before a final decision is made. To aid them in this decision personnel should refer to Facility Resources & Capabilities Chart. Also consideration should be given to the current hospital status listed on EMResource as well as the status of the MCHD EMS System. Routine Destinations The following Hospitals are within our transportation area and are approved for transport on a routine basis: • • • • • • • • • • • • • Conroe Regional Medical Center Memorial/Hermann Hospital – The Woodlands St. Luke’s – The Woodlands Community Hospital Houston Northwest Medical Center Northeast Medical Center Kingwood Medical Center Cleveland Regional Medical Center Tomball Regional Medical Center Methodist WillowBrook Hospital Cypress Fairbanks Medical Center Huntsville Memorial Hospital St. Luke’s – Lakeside St. Luke’s Hospital at the Vintage Satellite Emergency Rooms • Memorial Herman the Woodlands-West * *Personnel are encouraged to transport patients who have minor illness or minor trauma to satellite emergency rooms. Patients who may be admitted or require resources listed on the Facility Resources & Capabilities Chart should not be transported to satellite emergency rooms. Patients who require a sitter, security or physical restraint should not be transported to satellite emergency rooms. Requests for transport to other facilities (including facilities in the Texas Medical Center in Houston) should be approved by the on-duty Supervisor. The decision to approve such transport shall be based on the needs of the patient and the status level of the system. Please refer to the Facility Diversion Guidelines for more specific information on diversion. Revision Date 06/21/2012 69 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DESTINATION DETERMINATION CG 32 Page 70 TOC Designated and non-designated facilities play an important integral role in the trauma system. Patients with multi-system, blunt or penetrating trauma who are hemodynamically unstable and/or have respiratory compromise or altered mental status should be triaged and transported by EMS personnel to the nearest appropriate trauma facility. Mechanism of Injury alone does not mandate transport to a trauma facility in the patient without hemodynamic or anatomic criteria. The definition of appropriate facility is as follows: A hospital, not necessarily the nearest hospital, with the resources and capability to care for a patient based upon the patient’s medical needs. To better understand the capability of each facility refer to the Facility Resources & Capabilities Chart. Patient rights should be respected in the determination of hospital destination. In the event a competent trauma patient requests a destination discordant with the destination recommendation the In-Charge Paramedic should consult with the Field Supervisor. It is important to promptly notify facilities in order to allow for timely facility-specific trauma team alert mechanisms to be activated. Trauma Designations of local receiving facilities: Memorial-Hermann The Woodlands Level III Columbia Conroe Regional Hospital Level III Columbia Kingwood No Designation Tomball Regional Hospital No Designation Northeast Medical Center No Designation Houston Northwest Medical Center Level III Huntsville Memorial Hospital No Designation LBJ Level III Ben Taub Level I Memorial-Hermann-TMC Level I Children’s Memorial – TMC Level I (Pediatric) Texas Children’s Hospital Level I (Pediatric) Level I: Comprehensive trauma facility and tertiary care facility that has the resources and capability to provide total care for every aspect of injury continuum from research and prevention through rehabilitation. Note: Level I facility has neurosurgery available 24 hours/day. Level II: Major trauma facility that has the resources and capabilities to provide definitive trauma care to injury patients but may not be able to provide the same spectrum of care as a Level I trauma center. Note: Facility does not do research. Level III: Revision Date 06/21/2012 70 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DESTINATION DETERMINATION CG 32 Page 71 TOC General trauma facility that has the resources and capabilities to provide resuscitation, stabilization and assessment of trauma patients and can either provide treatment or arrange for appropriate transfer to a higher level trauma facility. Note: Facility has trauma surgeon available 24 hours/day Level IV: Basic trauma facility that has the resources and capability to provide resuscitation, stabilization or arrange for appropriate transfer of all trauma patients with major and severe injuries to a higher level trauma facility. Note: Facility does not have trauma surgeon available 24 hours/day. All facilities with Level III and Level IV designations are members of a trauma network. They are able to transfer patients to a more appropriate facility very quickly, often making transfer arrangements while the patient is being evaluated and stabilized. It is an appropriate use of resources to transport trauma patients to these facilities for evaluation. This prevents the Level I and Level II centers from being overwhelmed with patients that are not seriously injured. ***When transporting to Conroe Regional Medical Center or Memorial Hermann-The Woodlands, use the following criteria for Level I and Level II activation: Patients who fit the following criteria will be announced as a Level I Activation: 1. Confirmed blood pressure <90 at any time in adults and age-specific hypotension in children with traumatic injury 2. RR<14 or RR>30 in adult; < 20 or >38 in pediatric, including infant 3. GCS <8 with mechanism attributed to trauma 4. Intubated patients transferred from the scene, OR patients with respiratory compromise or obstruction 5. Penetrating wounds to the neck, chest, or abdomen 6. Extremity amputation/degloving/or mangling proximal to wrist or ankle 7. Transfer patients from other hospitals receiving blood to maintain vital signs Patients who meet the following criteria will be announced as a Level II Alert: 1. High-Risk auto crash (ejection, death in same compartment, extrication time > 20 min., vehicle intrusion > 18 in.) 2. Auto-pedestrian or Auto-bicycle with significant (>20 mph) impact 3. Motorcycle crash > 20 mph 4. Falls > 20 feet adult, pediatric > 10 ft. or 2-3 times height of the child 5. Penetrating injuries of the extremities that are proximal to elbow and knee 6. Paralysis (acute and traumatic origin) 7. Open fracture or multiple fracture of long bone 8. Open Skull fracture 9. Pregnant >20 weeks Revision Date 06/21/2012 71 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DESTINATION DETERMINATION CG 32 Page 72 TOC For specialized care such as for Stroke, ACS, and Burns, refer to the Facility Resources and Capabilities chart. Burns Inhalation Burns to hands 30% TBSA 2nd degree or higher < 12 or > 65 years of age 1. UTMB (consider AMP) 2. Memorial-Hermann Hospital Psychiatric Crisis Tri-County MHMR—ICES/PETC *** ***Eligibility is dependent on assessment using MCHD’s PETC Inclusion/Exclusion Criteria. Personnel must contact the PETC nurse to verify patient meets criteria and facility has space available. ***Refer to APP 21 – PETC Inclusion/Exclusion Criteria Revision Date 06/21/2012 72 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines Revision Date 11/10/2005 FACILITY DIVERSION CG 33 Page 73 TOC 73 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FACILITY DIVERSION CG 33 Page 74 TOC Diversion is a courtesy extended by MCHD EMS to a hospital facility, rather than a right to be demanded by hospitals. This policy reflects the guidelines for diversion established by the Southeast Texas Regional Advisory Committee on Trauma. The most current status of a hospital is available on the EMSystem. Definitions Appropriate Facility: A hospital, not necessarily located nearest the scene of an incident, that possesses the resources and capability to care for a patient based upon the patient’s specific medical needs. Bypass: The intentional movement of a patient from the scene of an incident to a specific hospital, not necessarily the nearest hospital, based upon the patient’s medical needs. Diversion: The intentional movement of a patient from the scene of an incident to an alternate hospital capable of caring for the patient at the request of that hospital because they advise that current circumstances indicate that hospital lacks the available resources or capability to treat the patient. Transfer: The movement of a patient from one hospital to another hospital based upon the patient’s medical needs. This procedure is also known as inter-hospital transport. Diversion Activation It is the responsibility of the designated hospital administrator to update the EMSystem’s status board through their individual log-on entry. The system requires updating every 4 hours. Currently that is the system in place for indicating a hospital status. Only under specific or catastrophic circumstances should MCHD accept a telephone diversion request from a facility. Diversion Activation Categories A request for diversion may be honored if any of the following conditions is reported by the requesting hospital: • • • • • Emergency Department (ED) saturation; Intensive Care Unit (ICU) saturation; Operating Room (OR) saturation; Equipment repair or maintenance; or Internal disaster. MCHD EMS personnel should absolutely honor a hospital’s diversion requests based on internal disaster. Revision Date 11/10/2005 74 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FACILITY DIVERSION CG 33 Page 75 TOC Communication of diversion status • A hospital should update the EMSystem status board every 4 hours. • A hospital should indicate the reason for their listed status. • Alarm should notify the on-duty Supervisor and duty crews diversion status and reason for diversion. • Alarm shall maintain a data resource of hospital administrators and Trauma Directors authorized to activate diversion implementation and deactivation. It is the hospitals’ responsibility to provide this information. Time Period for Diversion Status • A hospital may deactivate a diversion request at any time. • Diversion requests are effective for up to 4 hours, however, may be extended if necessary. • A hospital should update EMSystem to indicate continued status. • Failure by a hospital to update the system maybe considered to be off diversion status. Authorization for Override of Diversion Requests When a facility requests to be placed on diversion status, MCHD EMS personnel should attempt to divert appropriate patients to other facilities whenever possible. MCHD personnel should consider the condition of the patient, distance to alternate facilities, and the diversion status of alternate facilities in determining the destination for the patient. The on-line medical direction source (Supervisor and/or Assistant Director EMSClinical Services) may override a diversion request or a crew’s transport decision after consideration of the following: • • • • • • Severity of the patient’s condition; Distance and estimated time to an alternate appropriate facility; Patient’s request; Inclement weather conditions; System Level; and Whether all potential receiving facilities within a fifteen (15) minute radius of the patient’s location have requested diversion consideration. System Monitoring and QI MCHD EMS should document and report to the SETTRAC QI Committee those situations in which a diversion request has not been honored or has been overridden by the on-line medical direction source. Revision Date 11/10/2005 75 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines AIR MEDICAL UTILIZATION CG 34 Page 76 TOC Due to extended transport times to local trauma centers, it is sometimes in the best interest of the critically ill and/or injured patient to have them transported via helicopter. The utilization of helicopters as a means of rapid transport for critically ill or injured patients is an additional tool that allows MCHD-EMS to provide the highest level of care. Indication for Air Medical Utilization Utilization should be based on the following criteria: • The aircraft can deliver the patient to definitive care faster than ground transportation. • When transportation to a Level I or Level II Trauma Center is indicated and ground transportation time is greater than 30 minutes. • When specialized services are required that local receiving hospitals are not equipped to provide. • Severely injured patient(s) with extended extrication times. (> 30 min) • Mass casualty situations where EMS resources are exhausted. • Known or suspected head or spinal injuries with significant neurological deficits. • New neurological deficits/impairment in the presence of signs and symptoms suggestive of an acute intracerebral process. • Significant (urgent or critical) burns requiring a burn center. • Burns associated with significant injuries. • 2nd degree burn involving hands, feet, genitalia and face. • Inhalation burns. • Significant Chemical burns. • Significant Electrical burns. • Pediatric trauma and/or burns of any significance. Air Medical Resources should not be used in the following instances: • Pending arrest. • Trauma that can be managed at a Level III and/or Level IV facility. It is acceptable practice to transport a trauma patient to a closer facility for evaluation by the emergency department physician. Often times patients appear to be more seriously injured than they actually are. Following these guidelines allows the MCHD-EMS system to utilize trauma facilities and Air Medical Services in a way that best meets the needs of the patients and communities they serve. Coordination of Air Medical Utilization Responsibility for overall command and controlrests with the Incident Commander (IC) as outlined in the Joint EMS/Fire Department Operations policy. The highest-ranking MCHDEMS on-scene should assume the role of EMS Sector officer and have the ultimate responsibility for patient care. EMS Sector is responsible for keeping the IC informed of patient condition and status and any manpower, equipment or other needs that may arise. An Air Medical Provider (AMP) may be placed on standby by: • Calltaker Revision Date 11/10/2005 76 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines • • • • AIR MEDICAL UTILIZATION CG 34 Page 77 TOC Responding EMS unit First Responders on scene Fire personnel on scene Law enforcement on scene Air Medical should not be launched until one of the following occurs: • Supervisor on scene requests AMP • EMS unit is on scene and has made a determination that AMP is needed. The person requesting Air Medical Provider assistance shall provide Alarm with the following information: • Medic number • Brief report of patient condition • A precise location of the patient • Any unusual circumstances (bad weather, power lines down, etc.,) Alarm should provide the following information to the AMP communicator: • Requesting agencies name and callback number. • Exact scene location including; key map grid, street address, etc. • Reason for the request. • Type and extent of injury if known. • Number of patients. • Ground contact and the radio frequency to be utilized. Once the aircraft is enroute, the authority to terminate a request for services shall lie solely with the EMS sector officer, who, if different from the In-Charge providing primary patient care, should rely on the judgement of the In-Charge providing primary patient care. Additionally, the pilot has the authority to terminate the air medical response. The primary responsibility for patient care lies with the MCHD In-Charge. The Incident Command is responsible for overall scene safety and may designate a Safety Sector officer to assist in that role. The IC and or the EMS sector officer should directly relay patient information to the helicopter when requested by the Air Medical Pilot. The pilot is responsible for all aspects of the aircraft and shall make the final determination regarding any safety issues that directly effect safety of the aircraft and crew. (LZ location, weather, additional riders) Landing Zone (LZ) Requirements During normal daylight hours the LZ should be at least 60 x 60 feet. Additionally, it should be marked with one traffic cone at each corner and one traffic cone on the upwind side. During nighttime hours the LZ should be at least 100 x 100 feet with lighted cones at each corner and one lighted cone on the upwind side. Revision Date 11/10/2005 77 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines AIR MEDICAL UTILIZATION CG 34 Page 78 TOC Additionally, all emergency vehicles should turn off all emergency lights, especially strobe lights. Revision Date 11/10/2005 78 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CONTROLLED SUBSTANCES CG 35 Page 79 TOC The scheduled injectables should be signed for at the beginning of each shift with both InCharge EMT-P’s present. The sign-in sheet should reflect the number of scheduled injectables counted with documentation of the unique number assigned to each one. The on-coming Paramedic should sign in the appropriate space as receiving the scheduled injectables and the Paramedic leaving signs as “off-going” to document transfer of meds. Failure to sign for the scheduled injectables at the beginning of each shift may result in disciplinary action against both paramedics involved. 1st offense - Written warning 2nd offense - 48 hours off 3rd offense - 96 hours off 4th offense - Termination Policy violations remain on file for a twelve-month period. If an employee has no other occurrences during that time the policy violation is expunged from their record. The on-coming In-Charge EMT-P is responsible for carrying the key for the controlled injectables on his/her person at all times during the shift. Controlled Substances should be obtained from the lock boxes outside the Supervisor’s office specifically designated for transfer units. The Attendant with Paramedic Certification/Licensure from TDH should be responsible for signing the Controlled Substance sign-in log and maintaining security of the key. If both Attendants are paramedics the employee with the most seniority should be responsible for maintaining the Controlled Substances. Scheduled injectables are administered only after a person with extended medical authorization has received a consult. There are a few exceptions to this rule and they are addressed within the specific SDOs. The Medical Director has granted extended medical authorization to the following employees: • • • • • EMS Director Assistant Director EMS-Clinical Services Assistant Director EMS-Operations Clinical Supervisor Field Supervisors After administration of a scheduled injectable the Paramedic administering the medication should fill out the top portion of a Controlled Substance Usage and Tracking Form. Scheduled Injectables will not be replaced by the supervisory staff without complete documentation of usage. Contact the Supervisor as soon as possible for replacement. As long as the scheduled injectable usage has been properly documented, the ambulance may remain in-service with the minimum of one of each scheduled injectable while awaiting Revision Date 11/25/2008 79 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CONTROLLED SUBSTANCES CG 35 Page 80 TOC replacement. A unit should be placed out of service anytime all of one substance has been used. All medications should be checked frequently for expiration dates and may be administered through the end of a month (e.g. expires 6/02), unless the expiration date specifies the day of the month (e.g. 6/20/02). If possible, medications nearing their expiration date should be administered first in appropriate situations as scheduled injectables cannot be returned or exchanged. A Supervisor should be contacted for replacement before the medication expires. Units/stations with expired medications may result in disciplinary action for all InCharge Paramedics who have been responsible for maintaining the chain of custody for the controlled injectables. Revision Date 11/25/2008 80 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines MEDICATION STORAGE CG 36 Page 81 TOC The Texas Food Drug and Cosmetic Act states that drug or medical device is deemed adulterated if it is stored under conditions that result in the product’s safety or effectiveness being compromised. Drugs and medical devices that are stored in places that do not have proper environmental controls may become ineffective or dangerous. Products that are stored improperly in vehicles (i.e. ambulances, personal vehicles) are considered adulterated products and unsafe for human use. Guidelines for the proper storage of drugs and medical devices are generally recommended by the manufacturer of the product. Where no guidelines are listed on drug labels, the United States Pharmacopoeia recommends that products are stored at room temperature, away from humidity, and where necessary, away from light. For those devices that are not labeled with storage requirements, care should be taken to avoid extremes of temperature, humidity and light. All labels should be read and checked prior to storage. It is the responsibility of the operator to make sure that proper storage requirements are met. The Texas Department of State Health Services has the authority to detain and take action against those products that do not meet storage criteria. Rule Reference: 25TAC 157.11 Interpretation: The EMS provider licensure or relicensure applicant shall provide evidence of an operational policy which shall list the pharmaceuticals authorized by the medical director and which shall define the storage and maintenance procedures for each in accordance with the manufacturers and/or FDA recommendations. Compliance with the policy shall be incorporated into the provider’s Quality Management process and shall be documented on the unit readiness reports. MCHD EMS has adopted the following policy to assure compliance with the above mentioned rule. Medications and medical devices listed within this manual shall make use of the vehicle climate control system when the vehicle is in operation. During times when the vehicle is not in use, a generator-powered climate control system shall be utilized to maintain a constant temperature range. Extra items stored at stations for replacement shall be stored within a cabinet inside each station. Temperature control shall be maintained by keeping the thermostat at a consistent setting within the station. Revision Date 11/10/2005 81 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines Card 1- Abdominal Pain/Problems 01A01 Abdominal Pain 01C01 Fainting or near fainting >50 01C02 Females w/ faint/near faint 12-50 01C03 Males with pain above navel > 35 01C04 Females with pain above navel >45 01D01 Not alert Card 2-Allergies (Reactions)/Envenom (Bites, Stings 02A01 No difficulty breathing or swallowing 02A02 Spider bite 02B01 Unknown status (3rd party caller) 02C01 Difficulty breathing or swallowing 02C02 Special meds or injections used 02D01 Severe Respiratory Distress 02D02 Not alert 02D03 Condition worsening 02D04 Swarming Attack (bee, wasp,hornet) 02D05 Snakebite 02E01 Ineffective Breathing Card 3-Animal Bites/Attacks 03A01 Not Dangerous body area 03A02 Non-recent injuries (>6hrs) 03A03 Superficial bites 03B01 Possibly Dangerous body area 03B02 Serious hemorrhage 03B03 Unknown status (3rd party caller) 03D01 Unconscious or Arrest 03D02 Not alert 03D03 Dangerous body area 03D04 Large animal 03D05 Exotic animal 03D06 Attack or multiple animals Revision Date 11/10/2005 EMD DETERMINANTS VERSION 11 CG 37 Page 82 TOC Card 4-Assault/Sexual Assault (add prefix A or R) 04A01 Not Dangerous body area 04A02 Non-Recent injuries (>6hrs) 04B01 Possibly Dangerous body area 04B02 Serious hemorrhage 04B03 Unknown status (3rd party caller) 04D01 Unconscious or Arrest 04D02 Not alert 04D03 Abonormal breathing 04D04 Dangerous body area 04D05 Multiple victims Card 5- Back Pain (Non-Trauma or NonRec Trauma) 05A01 Non-Traumatic back pain 05A02 Non-Rect trauma back pain (>6hrs) 05C01 Fainting or near fainting >50 05D01 Not alert Card 6-Breathing Problems 06C01 Abnormal breathing 06C02 Cardiac history 06D01 Severe Respiratory Distress 06D02 Not alert 06D03 Clammy 06E01 Ineffective Breathing Card 7-Burns(Scalds)/Explosions 07A01 Burns <18% body area 07A02 Fire alarm (unknown situation) 07A03 Sunburn or Minor burns (18% body area 07D01 Unconscious or Arrest 07D02 Severe Respiratory Distress 07D03 Not alert 82 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines 07D04 07D05 Explosion Mulitple victims Card 8-Carbon Monoxide/Inhalation/Hazmat 08A01 C.O. alarm (w/o priority symptoms) 08B01 Alert without difficulty breathing 08C01 Alert with difficulty breathing 08D01 Unconscious or Arrest 08D02 Severe Respiratory Distress 08D03 Hazmat 08D04 Not alert 08D05 Multiple victims 08D06 Unknown status (3rd party caller) Card 9-Cardiac or Respiratory Arrest / Death 09O01 Expected Death (unquestionable) 09B01 Obvious Death (unquestionable) 09D01 Ineffective Breathing 09E01 Not Breathing at all 09E02 Breathing uncertain (agonal) 09E03 Hanging 09E04 Strangulation 09E05 Suffocation 09E06 Underwater Card 10-Chest Pain 10A01 Breathing normally <35 10C01 Abnormal breathing 10C02 Cardiac history 10C03 Cocaine 10C04 Breathing normally >35 10D01 Severe Respiratory Distress 10D02 Not alert 10D03 Clammy Card 11-Choking 11A01 Not choking now 11D01 Not alert 11D02 Abnormal breathing (Part obstn) Revision Date 11/10/2005 EMD DETERMINANTS VERSION 11 CG 37 11E01 Page 83 TOC Choking/Ineffective Breathing Card 12-Convulsions/Seizures 12A01 Not seizing now and breath regularly 12B01 Breathing regularly not verified <35 12C01 Pregnancy 12C02 Diabetic 12C03 Cardiac history 12D01 Not breathing 12D02 Continuous or Multiple seizures 12D03 Irregular breathing 12D04 Breathing regularly not verified >35 Card 13-Diabetic Problems 13A01 Alert 13C01 Not alert 13C02 Abnormal behavior 13C03 Abnormal breathing 13D01 Unconscious Card 14- Drowning (Near)/Diving/SCUBA Accident 14A01 Alert and breathing normally (no injuries & out of water) 14B01 Alert and breathing normally (injuries or in water) 14B02 Unknown status (3rd party caller) 14C01 Alert with abnormal breathing 14D01 Unconscious 14D02 Not alert 14D03 Diving or suspected neck injury 14D04 SCUBA accident Card 15-Electrocution/Lightning 15C01 Alert and breathing normally 15D01 Unconscious 15D02 Not disconnected from power 15D03 Power not off or hazard present 15D04 Long Fall (>6ft/2m) 15D05 Not alert 15D06 Abnormal breathing 83 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines 15D07 Unknown status (3rd party caller) 15E01 Not breathing/Ineffective breathing Card 16-Eye Problems/Injuries 16A01 Moderate eye injuries 16A02 Minor eye injuries 16A03 Medical eye problems 16B01 Severe eye injuries 16D01 Not alert Card 17-Falls 17O01 Public Assist (NOI/ASSO) 17A01 Not Dangerous body area 17A02 Non-recent(>6hrs) injuries 17B01 Possibly Dangerous body area 17B02 Serious hemorrhage 17B03 Unknown status (3rd party caller) 17D01 Dangerous body area 17D02 Long Fall (>6ft/2m) 17D03 Not Alert 17D04 Abnormal breathing Card 18-Headache 18A01 Breathing normally 18B01 Unknown status (3rd party caller) 18C01 Not alert 18C02 Abnormal breathing 18C03 Speech problems 18C04 Sudden onset of severe pain (<3 hrs) 18C05 Numbness or paralysis 18C06 Change in behavior (<3 hrs) Card 19-Heart Problems/A.I.C.D 19A01 Heart rate >50 bpm and <130 bpm 19A02 Chest Pain <35 19B01 Unknown status (3rd party caller) Revision Date 11/10/2005 EMD DETERMINANTS VERSION 11 CG 37 19C01 19C02 19C03 19C04 19C05 19C06 bpm 19D01 19D02 19D03 Page 84 TOC Firing of A.I.C.D. Abnormal breathing Chest Pain >35 Cardiac History Cocaine Heart rate <50 bpm and >130 Severe Respiratory Distress Not alert Clammy Card 20-Heat/Cold Exposure 20A01 Alert 20B01 Change in skin color 20B02 Unknown status (3rd party caller) 20C01 Cardiac history 20D01 Not alert Card 21-Hemorrhage/Lacerations 21A01 Not dangerous hemorrhage 21A02 Minor hemorrhage 21B01 Possibly dangerous hemorrhage 21B02 Serious hemorrhage 21B03 Bleeding disorder or blood thinners 21C01 Hemorrhage through tubes 21D01 Dangerous hemorrhage 21D02 Not alert 21D03 Abnormal breathing Card 22-Industrial/Machinery Accidents 22B01 Unknown situation (not caught) 22D01 Life status questionable 22D02 Caught in machinery (unknown) 22D03 Multiple victims Card 23-Overdose/Poisoning(Ingestion) 23O01 Poisoning (w/o PS) 23B01 Overdose (w/o PS) 23C01 Violent (police should secure) 23C02 Not alert 23C03 Abnormal breathing 23C04 Antidepressants (tricyclic) 23C05 Cocaine (or derivative) 84 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines 23C06 23C07 23C08 caller) 23C09 response 23D01 23D02 EMD DETERMINANTS VERSION 11 CG 37 Page 85 TOC Narcotics (heroin) Acid or alkali (lye) Unknown status (3rd party 26C01 ident) 26D01 Poison Control request for Card 27-Stab/ Gunshot /Pentr Trauma (prefix S,G,P) 27A01 Non-recent (>6hrs) Periphl wounds 27B01 Non-recent (>6hrs) 1 Central wound 27B02 Known single Peripheral wound 27B03 Serious hemorrhage 27B04 Unknown status (3rd party caller) 27D01 Unconscious or Arrest 27D02 Not alert 27D03 Central wounds 27D04 Multiple wounds 27D05 Multiple victims Unconscious Severe Respiratory Distress Card 24Pregnancy/Childbirth/Miscarriage 24A01 1st Trim hemorrhage or Miscarriage 24B01 Lbr (dlvry not imnt, >5 mths/20 wks) 24B02 Unknown status (3rd party caller) 24C01 2nd Trim hemorrhage or Miscarriage 24C02 1st Trimester Serious Hemorrahage 24D01 Breech or Cord 24D02 Head visible/out 24D03 Imnt delivery (>5 months/20 weeks) 24D04 3rd Trimester hemorrhage 24D05 High Risk complications 24D06 Baby born Card 25-Psychiatric/Abnormal Behavior/Suicide 25A01 Non-violent and non-suicidal (alert) 25B01 Violent (police should secure) 25B02 Threatening suicide 25B03 Near hang, strang, suffocation (alert) 25B04 Unknown status (3rd party caller) 25D01 Not alert Card 26-Sick Person (Specific Diagnosis) 26A01 No PS (cplnt 2-28 not ident) 26A2-28 Non-priority complaints 26B01 Unknown status (3rd party caller) Revision Date 11/10/2005 Cardiac HX (cplnt 2-28 not Not alert Card 28-Stroke (CVA) 28A01 Breathing normally<35 28B01 Unknown status (3rd party caller) 28C01 Not alert 28C02 Abnormal breathing 28C03 Speech or movement problems 28C04 Numbness or tingling 28C05 Stroke history 28C06 Breathing normally>35 Card 29- Traffic/Transportation Accidents 29A01 1st party caller with Not Dang Inj 29B01 Injuries 29B02 Multiple victims (one unit) 29B03 Multiple victims (additional units) 29B04 Serious hemorrhage 29B05 Unknown status (3rd party caller) 29D01 Major Incident (a through e) 29D02 High Mechanism (a through g) 29D03 Hazmat 29D04 Pinned (trapped) victim 29D05 Not alert 85 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines Card 30-Traumatic Injuries (Specific) 30A01 Not Dangerous body area 30A02 Non-recent injuries (>6hrs) 30B01 Possibly Dangerous body area 30B02 Serious hemorrhage 30D01 Dangerous body area 30D02 Not alert 30D03 Abnormal breathing EMD DETERMINANTS VERSION 11 CG 37 Page 86 TOC 33C03 Significant hemorrhage or shock 33C04 Possible ACS or MI (heart attack) 33C05 Acute severe pain 33C06 Emergency response requested 33D01 Suspect cardiac or respiratory arrest Card 31-Unconscious/ Fainting (Near) 31A01 1/near fainting episode & alert <35 31C01 Alert with abnormal breathing 31C02 Cardiac history 31C03 Multiple fainting episodes 31C04 1/near fainting episode and alert >35 31C05 Females 12-50 with abdominal pain 31D01 Unconscious (at end of interrogation) 31D02 Severe Respiratory Distress 31D03 Not alert 31E01 Ineffective Breathing Card 32- Unknown Problem (Man Down) 32B01 Standing,sitting,moving,or talking 32B02 Medical Alert notifications 32B03 Unknown status (3rd party caller) 32D01 Life Status Questionable Card 33-Interfacility/ Palliative Care 33A01 Acuity I (no priority symptoms 33A02 Acuity II (no priority symptoms) 33A03 Acuity III (no priority symptoms) 33C01 Not alert (acute change) 33C02 Abnormal breathing (acute onset) Revision Date 11/10/2005 86 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FILE TRANSFER OF PATIENT CARE RECORDS CG 38 Page 87 TOC A Patient Care Record (PCR) shall be accurately completed for each ambulance response to a 9-1-1 call for service and contain all available requested information regarding call demographics, patient assessment, care rendered and patient response to care. This also includes non-emergency responses and dedicated standbys with or without patient transport, calls where a unit has responded and there is no patient contact or response is cancelled before scene arrival and all transfers whether scheduled or non-scheduled. Completed PCR’s may not be altered or changed unless done by the individual that completed the form, except to add or change billing information, or add name and other pertinent demographic information if it was unknown at the time of the call. Intentional failure to complete a PCR when required may result in disciplinary action. Completed PCR’s are confidential patient medical records and access is limited to responding personnel, State EMS authority as part of an administrative investigative process, authorized medical facilities that received the transport and ambulance provider service payor sources. Copies of completed PCR’s may be provided to other sources only as legally permitted. The records may also be provided to the patient or patient responsible party by valid medical record release. PCR completion and dispersal Documentation of patient assessment and treatment information contained on PCR’s is the responsibility of personnel providing patient care. All MCHD employees providing patient care are required to sign the patient care record. Completed PCR’s may not be altered or changed except by the individual that completed the form, except as previously noted. If a paper PCR is utilized, any documentation error shall be lined through, and the correction shall have the patient attendant’s initials beside it. Any changes made to an automated PCR shall have documentation of those changes retained in the computer data base and correction logbook. Each PCR shall be accurately completed with all available and relevant information as described in the documentation standards for MCHD-EMS. Use of usual and customary abbreviations is permitted in the narrative section of the record or as defined in automated PCR predesignated picklists. Each PCR shall be accurately completed as soon as possible after the response or patient transport is completed and copies should be provided to the receiving facility in the customary manner. If the transport personnel are unable to complete the form prior to leaving the facility, the PCR shall be completed and returned to the receiving facility as soon as possible, but in no case later than 24 hours after completion of the call. If extenuating circumstances prevent this from taking place the ePCR Administrator should be notified so that copies of the PCR may be forwarded to the facility. Wait and return transfers receive two (2) incident numbers (one incident number to transport patient to destination and the second to return patient to originating location). Therefore, two (2) reports should be written. Revision Date 06/21/2012 87 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FILE TRANSFER OF PATIENT CARE RECORDS CG 38 Page 88 TOC Reports should be completed and “sync’d” immediately following a response, and must be completed prior to employees going home at end of their shift. In the event of an emergency (e.g. family emergency, hardware or software failure) preventing completion of a record prior to the end of the shift the following must occur. Contact your Supervisor and request permission to leave the call open Send an email to [email protected] Include the incident numbers(s) Explain why the PCR is incomplete Include name of the Supervisor who approved the incomplete report State when the report will be completed Employees must close the record(s) within one (1) calendar day from the date of service. Failure to follow any aspect of this directive will result in a written Employee Action Notice (EAN). Additional violations will result in an escalation of disciplinary action, up to and including Clinical Suspension, per District policy. The Supervisor should document that the employee called as well as the reason for noncompliance with the deadline time. An appointment should be made with the employee to complete the report as soon as possible. Documentation of this interaction will be placed in the employee file. Failure to contact the Supervisor to initiate this process will result in Clinical suspension until the patient care records are completed. Should Clinical Suspension occur as a result of non-compliance, employee WILL NOT be allowed to return to work until all reports are completed. The Assistant Director EMS, Supervisory staff and Medical Staff Services Coordinator will be notified of the employee’s Clinical suspension and documentation should be placed in employee files. When an employee has received two (2) Clinical Suspensions for open calls the third step in the disciplinary process will be one (1) shift off without pay. The employee MAY NOT be allowed to use PTO time or work an extra shift during the same week that he/she is suspended without pay. Once the fourth incident occurs the employee be reported to the Texas Department of Health for violations of the Texas Administrative Code Rule 157.36 (b), (1), (2), (3) and (28) and may be subject to a non-emergency suspension, decertification and revocation of their certification or licensure (see attached TDH Rules). Revision Date 06/21/2012 88 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FILE TRANSFER OF PATIENT CARE RECORDS CG 38 Page 89 TOC Daily transfer of the patient care record is important from a Clinical as well as a billing aspect. Therefore, in an effort to improve this procedure guidelines have been developed for file transfers to occur. Units that are on station at shift change should still attempt to file transfer before 0700 hrs. Units that are responding to emergency calls or posting should have until 0900 hrs. to complete this procedure. Peak trucks should file transfer before they sign out and go home. Review of open calls occurs daily at 0900. File transfers are to occur daily regardless of any open calls. If the on-coming crew notices calls from the previous shift they SHOULD perform a file transfer as soon as they are able. If you are unable to complete the file transfer, please notify the ePCR Administrator. This ensures that the Electronic Patient Care Record System server is working properly or has been reset. Remember you can file transfer as many times per shift as you choose or have time. Employees should complete reports immediately following the response, and not wait until the following morning. Overtime will not be authorized for employees who wait until the end of their shift to complete patient care records when sufficient time was available to complete the record during the shift. For example, an employee who submits for overtime to complete a record from 2000 hrs will not be paid overtime to stay late and complete the record without Supervisor approval. Revision Date 06/21/2012 89 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines ALLIED HEALTH CARE PROVIDERS CG 39 Page 90 TOC The purpose of this policy is to ensure compliance with the rules of the Texas State Board of Medical Examiners, the Texas State Board of Nurse Examiners, and the Texas Department of State Health Services. In accordance with these rules, Allied Health Care providers may accompany EMS personnel during the ambulance transport of a patient for the purposes of: 1. Providing additional personnel to allow the efficient and effective provision of care to critically ill or injured patients. 2. Monitoring and managing equipment, adjuncts, and medications with which the EMS personnel are not familiar (e.g.; IV pumps, ventilators, or unusual IV medications). . For the purpose of this policy, Allied Health Care providers are defined as: 1. Nursing personnel (LVNs, GN’s, and RN’s) 2. Respiratory Therapists or Respiratory Care Practitioners 3. Nurse Practitioners, Physician Assistants Allied Health Care providers are authorized to accompany ambulances in the MCHD EMS System when they are requested by the attending EMS personnel, the transferring physician, or the on-line medical control personnel. The attending Paramedic is ultimately responsible for the management of the patient while in the care of the EMS system. Allied Health Care providers may not independently treat patients while those patients are in the care of the EMS system. Either the protocols or the on-line physician must authorize all treatments and therapies. Orders from the transferring physician concerning care to be rendered during transport that is not in the current protocols must be given as written orders and turn in the patient care report. The specialized neonatal/pediatric team will be a recognized exception to this policy. The Director of the Neonatal/Pediatric Unit and the Medical Director for MCHD EMS will agree that the EMS personnel will be back up for the nurse(s) on the Pedi/Neonatal team. When a transferring physician requires specialized drugs or narcotics that are not in MCHD EMS stock, the physician shall provide the EMS personnel with the drugs/narcotics needed. The drugs/narcotics must be accompanied with a written order from the transferring physician. Drugs/narcotics not used will be wasted as the Controlled Substance Policy. The presence of an Allied Health Care provider does not exempt the EMS unit from proper staffing requirements set forth by TDSHS Rule §157.11 or proper paperwork. Revision Date 11/10/2005 90 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PRIMARY SURVEY/CABC’S CG 40 Page 91 TOC Through out the Protocols, the acronym “CABC's” is used to indicate the primary survey of the every patient. Our patient survey consists of the evaluation and, if needed, management of the following components: • Cervical spine • Level of consciousness • Airway • Breathing • Circulation The following is an outline for the assessment and management of these components. The patient survey includes (in order): 1. Obtain manual control of cervical spine, if indicated 2. Quickly establish level of consciousness (AVPU). 3. Evaluate airway. Establish patent airway if needed. 4. Evaluate breathing. Initiate ventilation or ventilatory assistance if needed. Assess for open chest wounds. Occlude any found. 5. Check for presence and adequacy of circulation. Initiate chest compressions if needed. Check for external bleeding. Control any significant bleeding found. Cervical Spine If there is any possibility of a spinal injury through mechanism of injury or level of medic’s suspicion, the provider should assume that one exists and approach the patient accordingly. Once permission to assess the patient is obtained, by verbal consent, the provider's next step on any patient with the possibility of spinal injury is to manually obtain control of the c-spine. This manual c-spine stabilization should be maintained until: 1. Further assessment clearly and absolutely rules out any possibility of spinal injury, 2. The spine is adequately immobilized with adjuncts which relieve the need for manual stabilization OR 3. The patient refuses further treatment or transport. According to BTLS, the following are indicators from the mechanism of injury that a potential spinal injury exists and that these patients should be immobilized: • Blunt trauma above the clavicles • Diving accident • Motor vehicle collision or bicycle accident • Fall • Stabbing or impalement anywhere near the spinal column • Shooting or blast injury to the torso • Any violent injury with forces that could act on the spinal column or cord Patients who are found unconscious on the floor are considered to have a cervical spinal injury unless a bystander or family member can give an accurate account of how the patient got to the floor. Proper cervical spine protection includes manual Revision Date 11/10/2005 91 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PRIMARY SURVEY/CABC’S CG 40 Page 92 TOC stabilization, C-collar application, patient placement, via logroll, onto long backboard, webbing application and headbed/towel roll/head block application. Placing patient in a Scoop Stretcher does not constitute spinal motion restriction. If the patient is placed in a Scoop Stretcher, then spinal immobilization can be accomplished as follows: manual stabilization, C-collar application, Scoop stretcher application, placement of patient and Scoop stretcher onto back board, webbing application, and headbed/towel roll/headblock application. Level of Consciousness The level of consciousness should be briefly assessed next, to determine only the patient's rating on the “AVPU” scale (Alert, responsive to Pain, responsive to Voice, Unresponsive). Further assessment of the level of consciousness is to be deferred until the secondary survey. Airway The patient's airway should next be evaluated for patency. If there is any indication of a compromise in the patient's airway or any threat that such a compromise will develop, the provider should immediately intervene to secure the airway. Indications of compromise may be as overt as apnea or a visible obstruction, or may be indicated by a less obvious sign such as airway noises (stridor, snoring, gurgling, etc). The airway should be secured first with positioning, using a jaw-thrust if spinal injury cannot be ruled out or a head-tilt/chin-lift if spinal injury is not a concern. If material should be physically removed from the airway, this should be done next using abdominal or chest thrusts, a finger sweep, and/or oral suctioning as appropriate. If the patient's level of consciousness is diminished, an airway adjunct should be placed next. Use an oral airway if the patient will tolerate it, otherwise use a nasal trumpet. Manual positioning should be maintained concurrently with the use of such an adjunct. If possible, the airway should next be definitively secured with ET intubation. Even in the patient whose airway is initially patent, the provider should continuously reassess and be prepared to intervene against any airway compromise. Breathing The next component to be assessed is the patient's respiratory status. If the patient is not breathing spontaneously, ventilation with supplemental oxygen should be initiated immediately. If the patient is breathing spontaneously, the adequacy of the patient's respiratory effort should be evaluated. If the patient's rate or tidal volume is inadequate, assisted ventilation with supplemental oxygen is to be provided immediately. The patient's chest should also be rapidly assessed for open wounds which would compromise respiration. If any open chest wound is found, it should be immediately occluded, initially with the provider's gloved hand and then with an occlusive dressing. The bag-valve-mask device with oxygen at 10-15 l/min and a reservoir bag is the preferred method of providing ventilation. The demand-valve (oxygen-driven, manually triggered device) should not be used unless a properly functioning BVM is not available as the demand-valve offers no sense of compliance or resistance to the Revision Date 11/10/2005 92 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines PRIMARY SURVEY/CABC’S CG 40 Page 93 TOC operator and often results in excessive gastric distention. If possible, the airway should always be secured with ET intubation if positive pressure ventilation is to be instituted. As with the airway, the provider should continuously reassess the ventilatory status of even the most stable patient and be prepared to rapidly intervene if respiratory compromise develops. Circulation The patient shall next be assessed for: 1. Adequate circulation AND 2. For the presence of major external hemorrhage. If the patient is awake or at least responsive to verbal or physical stimulus, the provider shall assume that circulation is adequate for the moment and move on. If the patient is unresponsive, the provider should assess for the presence and adequacy of a palpable carotid pulse. If the patient does not have a palpable carotid pulse, or has a pulse of less than 30/min in the adult (less than 40/min in a child or less than 60/min in an infant), the provider should initiate chest compressions. A more accurate evaluation of the patient's perfusion status should be done during the secondary survey. Next, rapidly assess the patient for external bleeding. If major bleeding is found, it should be immediately controlled with direct pressure. Revision Date 11/10/2005 93 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FOCUSED AND DETAILED EXAM CG 41 Page 94 TOC FOCUSED AND DETAILED EXAMINATIONS The focused exam is an assessment that is pertinent to the patient’s chief complaint. The detailed physical exam is a systematic, whole body assessment that evaluates physical findings and significant history. It is performed after the initial assessment has determined that there is no life threat, or interventions have been made to lessen that threat. The amount of time expended or even the necessity of these exams is directly dependent on the patient’s condition. All remarkable findings, associated symptoms, and pertinent negatives (ASPN) are to be documented. This is also the time that an interview is conducted for history. This information is to be included in the patient report to the health care provider who receives this patient as well as in the patient care report. The SAMPLE mnemonic is easily remembered as: S - Signs/symptoms A - Allergies M - Medications (prescribed, over the counter or elicit) P - Pertinent past medical history L - Last oral intake E - Events that lead up to calling EMS OOnset of Symptoms P - Provocation Q - Quality of pain R - Radiation of pain S - Severity T - Time A - Associated S - Symptoms P - Pertinent N - Negatives TRAUMA SURVEY A helpful mnemonic to assess trauma patients comes from the Basic Trauma Life Support class. Head, Neck, Chest, Abdomen and Extremities can be systematically checked using DCAP-BTLS, or if you prefer, DCAP-BLSTIC. D - Deformity C - Contusions A - Abrasions P - Penetrations or Paradoxical Movement Revision Date 11/10/2005 B - Burns L - Lacerations S - Stability T - Tenderness I - Instability C - Crepitus 94 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FOCUSED AND DETAILED EXAM CG 41 Page 95 TOC TRAUMA HEAD-TO-TOE SURVEY Head, Face, Eyes - Deformities - Depressions - Contusions - Hematomas/Battle’s Signs - Lacerations - Pupil size, equality, reaction to light - Extraoccular motions - Raccoon’s eyes - Blink reflex Neck - Point tenderness Alignment Neck Veins: Flat or Distended Trachea: Midline or Deviated Abdomen Localized Tenderness Rebound Pain/Referred Pain Pulsatile Mass Distention Pelvis - Extremities Deformities Pain on Palpation Contusions, Abrasions, Hematomas Ecchymosis Genitalia Trauma - Foreign Bodies Penetrations Burns Facial Symmetry Fractures Discharge from ears, nose Loose teeth, Dentures Oral Secretions, vomitus or bleeding Contacts or Glasses Chest - Paradoxical Motion - Breath/Heart Sounds - Sternal Inspection - Crepitus - Retractions with Respirations - Contusions, Abrasions, Hematomas - Sucking Chest Wounds Phenomenon - Rigidity Bowel Sounds Ecchymosis - Distal Circulation Range of Motion Motor/Sensory Response Abnormalities/Deformities Contusions, Abrasions, Hematomas Skin Color/Tugor Back Pain Deformities Contusions, Abrasions Revision Date 11/10/2005 95 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FOCUSED AND DETAILED EXAM CG 41 Page 96 TOC MEDICAL/CARDIAC HEAD-TO-TOE SURVEY Head, Face, Eyes Pupil Size, Equality, Reaction to Light Extraoccular Motions Conjunctiva Color Blink Reflex Contacts or Glasses Facial Symmetry Neck - Carotid Artery Bruits Neck Veins: Flat or Distended Trachea: Midline or Deviated Nuchal Rigidity Abdomen Localized Tenderness Rebound Pain/Referred Pain Pulsatile Mass Distention - Skin Color and Quality Discharge form Ears, Nose Mouth Odors Loose Teeth, Dentures Mucous Membrane Color Chest - Paradoxical Motion - Breath/Heart Sounds - Retractions with Respirations - Rigidity Bowel Sounds Ecchymosis Extremities Distal Circulation Range of Motion Motor/Sensory Response Abnormalities/Deformities Skin Color/Tugor Cyanosis, Clubbing, Edema Revision Date 11/10/2005 96 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines FOCUSED AND DETAILED EXAM CG 41 Page 97 TOC Occasionally, EMS personnel will encounter a patient whose injury can only be treated definitively with surgery. When confronted with such a patient, the attending EMS personnel shall institute the basic interventions noted here and begin transport to an appropriate facility AS SOON AS POSSIBLE. Rapid transport includes utilizing the helicopter to transport the patient, when doing so expedites the transport of the patient to the most appropriate facility. See the “Air Medical Utilization” protocol for specific guidelines regarding this issue. ONLY THE FOLLOWING INTERVENTIONS ARE TO BE DONE PRIOR TO INITIATING TRANSPORT: • • • • • • • • Spinal Motion Restriction Spinal Motion Restriction procedures may need to be modified and abbreviated to achieve rapid transport in some situations. Such deviations should be well documented and should still ensure that the patient is adequately and appropriate secured and immobilized. The KED should not be used to immobilize sitting patients in a rapid transport situation. BLS airway and ventiation procedures (Oxygen administration, OPA, BVM, etc.) Defibrillation (only the initial shock) Intubation IF it can be accomplished rapidly (two attempts) Surgical airway Occlusion of open chest wounds Vital signs (may use peripheral pulses to estimate—See “Diagnostic Tools and Procedures” rationale) Freeing patient from entrapment All other interventions are to be done once enroute to the hospital. If entrapment delays transport, other interventions may be instituted on-scene while awaiting the patient to be freed (e.g., bandaging/splinting, IV initiation, cardiac monitoring, etc.). The following represent patients for whom rapid transport is suggested: • • • • • • • • • Patients meeting the BTLS guidelines for “load and go situation” Adult and Pediatric Critical Trauma as defined in "Destination Determination" protocol Head Injury or CVA with evidence of increasing ICP Suspected aortic aneurysm Suspected ectopic pregnancy, abruptio placenta, or uterine rupture All abdominal pain patients with unstable vital signs (tachycardia with normotension, hypotension) Obstetrical emergencies resulting in possible fetal distress, such as limb presentation, breech delivery, or prolapsed cord GI bleeding with unstable vital signs (tachycardia with normotension or hypotension) Any other patient requiring urgent surgical intervention. Revision Date 11/10/2005 97 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 98 TOC STANDARDS FOR DOCUMENTATION All providers shall have the responsibility for ensuring that all EMS incidents to which a unit is dispatched are documented. This includes all incidents in which a patient is treated and/or transported by the responding unit; the patient refuses any aspect of EMS service; the patient has left the scene; unfounded calls; the patient is referred to another unit or service for transport; and people on scene meeting the definition of “no patient.” The provider shall have the responsibility for ensuring that a patient care report is prepared. The patient care report should include signatures where appropriate. ECG data should be uploaded and linked to the PCR. Key: Operations Information Componentand should be documented Bold items indicate an “Absolute” Italicized itemsCompletion indicate examples of terminology component that may beshall usedrequire to document Standard: of this documentation properthat component. documentation of all the absolute criteria listed as follows: For all required components and criteria that cannot be obtained, place NA for Not Date of Incident Applicable or “0” (zero) for number fields. Operations Information Component Standard: Completion of this documentation shall require proper documentation of all absolute criteria listed as follows: Location of incident, including street address and city Unit designation of dispatched unit Complete and Correct Incident number as assigned by Alarm Crewmembers assigned to call, identified by employee number and signature Destination If delivered to a hospital other than the ED, document area of hospital (Rm. #, ICU, L&D) Dispatch priority Dispatch Determinant Transport Priority Mileage Appropriate Signatures Goal: Proper documentation of 100% of the above criteria Revision Date 7/23/2010 98 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 99 TOC Acceptable Terminology: Destination (where patient was delivered) If a patient was not transported, the Call Outcome section should include the reason. Refusal; Dead on scene; No Injury, etc. If the chart is generated by a non-transporting unit, the Call Outcome section should include the patient’s disposition. Refusal; Dead on scene; transported by (transporting unit’s service name and designation), etc. If the patient is delivered to the Emergency Department, the Call Outcome section should include the name of the facility. Conroe Medical Center, Houston Northwest, Hermann, etc. If the patient is delivered to a facility/location other than the Emergency Department, the Call Outcome section include the name of the facility/location. Dr. Jones’s Office, Hermann PICU, Conroe Medical Center CCU, AMP Landing Zone, etc. Dispatch Priority Shall be documented in the Response Screen as how the crew responded to the call. Emergency = Priority 1 or 2 Non-Emergency = Priority 3 or 4 Other = Walk in Patient Dispatch Determinant Shall be documented in the Response Screen as received from the crew from Alarm in the format of Dr. Jeff Clawson EMD guidelines. Transport Priority Shall be documented in the Call Outcome as follows: Patient condition (Non-urgent, Urgent, Critical, CPR, etc.) Transport Status (Non-emergency, Emergency) Mileage Shall be documented as total miles including decimal points from scene to destination. Revision Date 7/23/2010 99 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 100 TOC Appropriate Signatures Shall be obtained for Refusals, Refusal of Treatment, No injuries, etc. If patient cannot sign, select the appropriate option from the “pull down” menu. Patient Demographics Component Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all absolute criteria. Patient name Patient age Date of Birth Patient’s sex Name of Guardian/Next of Kin (If applicable for minors and geriatric) Mailing address, City, State, Zip Code Home Telephone Number Social Security Number “Bill To” Information Medicare/Medicaid Number (If applicable) Insurance Company Name (If applicable) Insurance policy/group number (If applicable) Insurance Phone Number (If applicable) Goal: Proper documentation of 100% of the above criteria Acceptable Terminology: If information is unobtainable, place “0” (zeros) in number fields. If patient has no address, use “NFA” for no fixed address. All minors should have Next of Kin/Guardian documented. Primary Survey Standard: An evaluation of the “satisfactory” completion of this documentation component shall require the documentation of all of the absolute criteria and at least 50% of the remaining criteria. The criteria are as follows. The Primary Assessment should be overly stated as: Revision Date 7/23/2010 100 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 101 TOC Documentation as to the absence, possibility, or presence of an injury to the patient’s spine. If an injury to the cervical spine is observed or suspected, you should state when/how you maintained the C-spine manually. Documentation concerning the patency of the patient’s airway. Documentation concerning the presence or absence and the quality of the patient’s breathing. Documentation concerning the presence or absence of a palpable pulse. If the patient has palpable pulse, the provider should document at which site the pulse was palpated. Documentation as to the presence or absence of visible external bleeding. If external bleeding is present, the provider should document (in general terms) the rate and quantity of bleeding. Documentation of patient’s mental status using the “AVPU” scale. The provider shall document the highest score on this scale. Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: Airway If the patient’s airway is not intact, state the factors which are contributing to the compromise. Breathing In describing the quality of the patient’s respirations, the following terms are acceptable: Uncomplicated, non-labored, labored, snoring, agonal, wheezing, tachypnic, shallow, Kussmaul, Cheynne-Stokes, gasping, and absent. Circulation When documenting the presence of a pulse, the following terms may be used: Faint, weak, thready, rapid, regular, irregular, bounding, slow, bradycardic, tachycardic, and strong Bleeding When documenting the presence and extent of external bleeding, first state whether the bleeding is venous or arterial. Then describe the quantity/quality of the bleeding. Stopped PTA: bleeding that ceased prior to the arrival of EMS units either by self-clotting or other interventions. Revision Date 7/23/2010 101 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 102 TOC Minimal: slow capillary bleeding easily stopped by direct pressure Moderate: venous or arterial bleeding that is controlled with firm direct pressure and bulky dressing. Severe: venous or arterial bleeding that cannot be controlled by firm direct pressure, bulky dressing, or utilization of pressure points. Other terms that may be used include: Spurting, bright red, dark red, seeping, oozing, and steady. Chief Complaint Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. The chief complaint should be “what the patient states” in response to the provider’s inquiry. It should not be the provider’s assessment of what is wrong. If the patient is unable to verbalize or does not answer the provider’s questions, then there is no “chief complaint.” This is to be documented as “patient unable to give chief complaint.” Goal: Proper documentation of the patient’s chief complaint as stated by the patient and not the provider’s assessment. Vital Signs Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all the absolute criteria and at least 50% of the remaining criteria. Criteria for the component are as follows. Blood pressure Pulse rate Respiratory Rate If the pulse is regular or irregular The vital signs appropriately obtained. Goal: Proper documentation of 100% of above criteria. Vital signs are defined as blood pressure (auscultated if possible with both systolic and diastolic), capillary refill (in the pediatric patient less than one year of age), pulse or heart rate, and respiratory rate. Revision Date 7/23/2010 102 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 103 TOC Repeat sets of vital signs should be obtained every 5 minutes in the critical, or non-stable patient, or every fifteen minutes or less in the stable, non-critical patient. Capillary refill (CR) may be used as an adjunct to blood pressure in assessing/describing the perfusion status of the pediatric patient. CR is to be charted in terms of seconds (i.e., CR < 2 sec.). A palpated B/P is acceptable documentation ONLY: A. As an additional vital sign in the non-urgent patient in whom an auscultated B/P has already been obtained and was within accepted normal limits. B. In the critical trauma patient in whom serial palpated blood pressures are being obtained. C. In the patient in whom an auscultated blood pressure ABSOLUTELY cannot be obtained. In this case, the chart SHOULD reflect the fact that an auscultated blood pressure was unobtainable and the reason why. Patients refusing treatment/transport should have one complete set of vital signs documented. If the vital signs are not within accepted normal limits, a second set should be documented, a minimum of five minutes after the first set. If patient refuses vital signs, document as such in your narrative. Patients being transported from a medical facility to their home or a nursing home should have at least one set of vital signs documented. If the initial set of vital signs are not within accepted normal limits, a second set should be obtained. Patients transported from one hospital to another or from a nursing home or other facility to a hospital should have a minimum of two sets of vital signs documented. All other transported patients should have a minimum of two sets of vital signs documented. The chart should reflect the reason(s) for any deviation from the standards required by the protocol for obtaining vital signs (i.e., patient refusing v/s, extremely short transport time, etc.). Secondary Assessment Standard: An evaluation of "satisfactory" completion of this documentation component shall require proper documentation of all of the absolute criteria and 50% of the remaining criteria. The criteria for this component are as follows: Level of consciousness Any findings relating directly to the patient's chief Revision Date 7/23/2010 103 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 104 TOC complaint and/or EMS differential. This may include the Medical Assessment Screens (i.e. Respiratory, Fibrinolytic, 12-Lead, Cardiac Arrest, etc.) The presence or absence of associated findings relating indirectly to the patient's chief complaint and/or EMS differential (i.e., injuries commonly found with a particular mechanism of injury, symptoms commonly associated with a particular illness, etc.) A complete "Head-to-toe" exam shall be performed on all trauma patients to rule out the possibility of associated injuries secondary to the mechanism. A focused exam shall be performed on all medical patients to reveal physical findings associated with the patient’s medical disease/illness. Breath sounds (when applicable) Distal pulses Neuro sensation Range of motion of extremities Skin assessment Pupillary Response Goal: Proper documentation of 100% of above criteria. Acceptable terminology/parameters: The patient's level of consciousness should be documented on all patient contacts, including patient refusals. Full orientation refers to the patient that is oriented to person, place, time, and event. Acceptable terms include. Alert and Oriented to PPTE (Person, Place, Time, and Event) or X4 (if all four) Awake and Oriented to_______ only Obtunded Decreased level of consciousness AND arousable to (voice, physical stimulus, pain) only (should chart response to stimulus) Unresponsive A complete "Head-to-Toe” exam should include the exam and evaluation of the patient's head, chest, back, abdomen, and extremities for injury and/or abnormalities. Assessment of the patient's skin should be charted on all assessed patients, and includes the evaluation and documentation of the patient's skin temperature, moisture, color, and turgor. Revision Date 7/23/2010 104 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 105 TOC Temperature may be described as warm, cool, etc.. Moisture may be described as dry, diaphoretic, etc. Color may be described either by color (i.e., pink) or by quality of color (i.e. fair, pale, etc.). Turgor may be described as fair, good etc. or by describing the degree of skin tenting (right forearm skin tented for 3 seconds). Breath sounds should be auscultated in all patients with the possibility of respiratory compromise, either for medical or traumatic reasons. Because prehospital differentiation of rales versus rhonchi is difficult, breath sounds should be described as how they sound, such as: wet, coarse, diminished, absent, wheezing, etc. Distal pulses refer to the presence or absence of radial and/or pedal pulses distal to any injury. The distal pulse should be evaluated prior to, and immediately following, the immobilization and/or bandaging of an injury. An evaluation of neurological sensation should be obtained secondary to any injury to check for deficits. Range of Motion (ROM) should be evaluated secondary to an injury or CVA. ROM can be described as “full,” “normal,” “decreased,” “absent,” etc. “Not Assessed” should be documented in all areas of the patient exam whenever the exam was not performed. Mechanism of Injury Standard: An evaluation of “satisfactory” completion of this documentation component shall require the proper documentation of all the absolute criteria. For MVC’s: Damage to the windshield, steering wheel, dash, or other appropriate component of the interior Direction and nature of impact Location and extent of exterior damage (using the Vehicle Damage Rating Scale) Use of, and type of restraint (i.e. seatbelt, airbag) For other injuries: Clear description of mechanism such as the device or weapon, length of knife or implement, speed or force, height of fall, etc. For all injuries: Any patient statement as to loss of consciousness or other details of mechanism (i.e. patient states he did not strike the steering wheel.) Goal : Proper documentation of 100% of the above criteria. Revision Date 7/23/2010 105 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 106 TOC History of Present Injury/Illness Standard: An evaluation of “satisfactory” completion of this documentation component shall require the proper documentation of all the absolute criteria and at least 50% of the remaining criteria. The criteria for this component are as follows: Onset of the event or signs/symptoms? What precipitated the events/symptoms? How have the symptoms progressed or changed? What aggravates or alleviates the problem? Any Third party information (e.g. the nursing home’s c/c, witness statements, etc.) If the patient is returning home (or to a nursing home, etc) the following information should be included: When the patient was admitted Why the patient was admitted General overview of treatment while in facility Goal: Proper documentation of 100% of the above criteria. Previous Medical History (PMHX) Standard: An evaluation of “satisfactory” completion of this documentation component shall require the proper documentation of all the absolute criteria. The criteria for this component is as follows: Any previous medical history stated by the patient, family, care givers, etc. or that is documented in the patient’s chart or medical record. Any recent past major surgeries. Patient’s private physician (if they have one) Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: *N/A is NOT an appropriate statement as the previous medical history is applicable to any and all patients. If the patient has no pertinent previous medical history, document as “none.” If the patient PMHX is unknown, document as “unknown.” Home Medications/Allergies Standard: An evaluation of “satisfactory” completion of this documentation component shall require the proper documentation of all the absolute criteria is as follows: Should include all of the patient’s prescription medications. Should include all of the patient’s known allergies to medications. Goal: Proper documentation of 100% of the above criteria. Revision Date 7/23/2010 106 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 107 TOC Acceptable Terminology: *N/A is NOT an appropriate statement as medications and allergies are applicable to any and all patients. If the patient does not take any medications, document as none. Med List with patient is not an acceptable notation of the patient’s medications If the patient does not know the name of a medication, document why the medication is taken. (E.g. unknown anti-HTN medication) If the medication information is not available, document as unknown. The chart should reflect the reason you were not able to obtain the medication information. *Over the Counter medications taken PRN, unless pertinent to the present episode, are not required to be noted (e.g. Advil, Sudafed, etc.) If the patient has no allergies to medications, document as none,NKDA, or NDA. If the patient’s drug allergies are unknown, document as unknown. The chart should reflect the reason you were not able to obtain the medication allergy information. Other Diagnostics Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component are as follows: Blood glucose levels should be obtained in accordance with the standards set by protocol and charted as the numeric value and the units, which are mg/dl. Temperature should be obtained/charted on all patients as required per protocol. A Pulse Oximetry reading should be obtained/charted on all patients presenting with a respiratory complaint, chest pain, or any other presentation of decreased perfusion. Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: Blood glucose levels should be obtained on all patients who experience a seizure prior to arrival of EMS or while in EMS care, have diabetic complications, altered mental status, or any other conditions where glucose monitoring is necessary. Revision Date 7/23/2010 107 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 108 TOC Blood Glucose levels are to be documented as the numerical value and the proper units (mg/dl). If Blood Glucose is NOT obtained using an electronic glucometer, state that the value is estimated. Temperature should be documented in degrees Fahrenheit. The method by which the temperature was obtained should document. (Oral, Tympanic, Rectal, or Temporal). Pulse Oximetry readings should be noted as a percentage, and if the reading was obtained while the patient was on room air or on oxygen. (If on oxygen, state the device and liter flow) Airway/Ventilation Management Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component are as follows: The chart should reflect all airway interventions performed , if any. The chart should reflect the field personnel who performed each intervention. The number of attempts at obtaining each type of airway. Confirmation of breath sounds by auscultation. If manual airway, note method used (e.g. jaw thrust, etc). If airway is used, note size of airway. If intubation, document all in the intubation screens. If suctioning, document type of suction, type/size of catheter. Goal: Proper documentation of 100% of above criteria. Acceptable Terminology: When documenting breath sounds, document what the Breath sounds sound like, rather than try to differentiate between Rales and Rhonchi. (E.g. wet, course, gurgling, wheezes, etc.) ECG/Electrical Therapy Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component are as follows: The ECG should be documented for all patients on whom it is obtained. The chart should reflect the interpretation of the initial rhythm, and all subsequent rhythm changes. Revision Date 7/23/2010 108 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 109 TOC A rhythm strip should be submitted to the Clinical Department with Incident number on strip. If Cardioversion or Defibrillation is used, the following information should be noted: Electrical Power Setting If cardioversion is synchronized or non-synchronized. Field personnel performing cardioversion If Transcutaneous Pacing (TCP) is used, the following information should be noted: Pacing rate Milliamps used Presence/absence of electrical capture. Presence/absence of mechanical capture. Field personnel applying TCP If multi lead ECG is used, the following information should be noted: Leads used (i.e. MCL1) Interpretation of rhythm Field personnel performing multi-lead ECG If 12-Lead ECG is used, the following information should be noted: Interpretation of the 12-Lead ECG Field personnel performing 12-Lead ECG Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: When Pacing, state if the Pacer is set to fixed or demand. Electrical power settings should be in units of joules or Watts/sec. Nonsynchronized cardioversion may be referred to as Defibrillation. If obtaining a 12-Lead ECG, it should be noted that the Interpretation of the 12-Lead is either that of themachine’s algorithm or the field personnel. If the interpretation is that of the attendant, document the leads the specific findings were found (e.g. Possible Anterior wall MI with ST segment elevation in Leads V3 and V4.) Revision Date 7/23/2010 109 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 110 TOC Oxygenation Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component is as follows: The chart should reflect all oxygen administration to the patient, including: Delivery device Liter flow Any changes in oxygen therapy Indication Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: Devices may be described as: NRB, NC, SFM, VenturiMask, Tracheal Tube, Capno Mask etc. Units should be expressed in lpm. Spinal Immobilization Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component are as follows: The chart should reflect any and all spinal restriction procedures. Goal: The proper documentation of 100% of the above criteria. Acceptable Terminology: Full Spinal Motion Restriction is defined as including a Cervical collar, long board (or equivalent device), A system for strapping the patient to the long board, And some form of head immobilization. CC=Cervical. Collar BB=Backboard KED=Kendrick Extrication Device CID=Cervical Immobilization Device HID=Head Immobilization Device Revision Date 7/23/2010 110 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 111 TOC BLS Therapy Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component are as follows: Control of bleeding (if present) Type/location of splint/bandage applied Presence or absence of distal pulse prior to and following the application of a bandage or splint. CPR performed (if applicable) MAST applied and/or inflated External cooling/warming as required per protocol Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: Control of bleeding may be described by direct pressure, pressure points, or elevation. The type of bandage may be documented as pressure, occlusive, sterile, etc. The type of splint needs to be described in the chart (e.g. traction splint applied to left lower extremity) The time CPR was started, as well as who performed CPR, needs to be stated in the chart. Document any pauses for interruptions, delays etc. External cooling includes the removal of excess clothing, application of cool, wet compresses, chemical cold packs, ice packs, etc. External warming refers to the removal of wet clothing, use of blankets, chemical heat packs, etc. IV Therapy Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all the absolute criteria. Criteria for this component is as follows: IV site Revision Date 7/23/2010 111 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 112 TOC Size of IV catheter Number of attempts IV fluid Drip rate Personnel who started the IV line Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: The IV site may be described as left hand, left AC, right wrist, etc. IV fluid may be abbreviated as follows: Normal Saline: NS, NaCl, 0.9%NS Drip rate may be abbreviated as follows: TKO, KVO, W/O (wide open), ___cc/hr. Medication Administered Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component is as follows: Name of medications being administered Amount of medication administered Route medication administered Field personnel administering the medication Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: Medications may be documented as trade or generic names. Amount given should be in mg, g, etc. and NOT in cc or ml. Route given may be abbreviated as IV, IO, PO, SL, SQ, IM, PR. Each medication and its subsequent dose should be charted separately e.g. (The third dose of Epi 1:1,000 in CPR would be a separate entry). Revision Date 7/23/2010 112 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 113 TOC Other ALS Therapy Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component is as follows: Procedure or intervention performed Number of attempts at the procedure or intervention Field personnel performing the procedure or intervention Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: Other ALS Therapy includes Surgical Airway, Chest Decompression, Nasogastric Tubes, and Vagal Maneuvers. Interventions performed prior to EMS arrival shall be documented as such in the intervention screen. Additional comments in narrative indicating procedure was continued or monitored enroute. Time Intervals Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component is as follows: Time call received by Dispatch Time call was dispatched Time unit responded Time unit arrived on scene Time of patient contact Time of arrival of transporting unit (if unit generating the chart is not transporting the patients in the case of First Responders, when helicopter ambulances are utilized, etc.) Time unit cleared from the scene (if not transporting the patient) Time enroute to the receiving facility Time unit arrived at receiving facility Time available for another call Times are to be documented with every set of vital signs Times are to be documented with all medications are administered Times are to be documented with all procedures performed Revision Date 7/23/2010 113 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 114 TOC Acceptable Terminology: Procedures include ECG, Cardioversion, Defibrillation, Transcutaneous Pacing (TCP), Surgical Airway, Needle Chest Decompression, Naso-gastric tube, and Vagal maneuvers. Consults Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component are as follows: If consult was required, reflect that it was made. All orders requested, received, or denied by Supervisor/Medical Director should be documented. The name of Supervisor (or Medical Director, if contacted) should be noted in the chart. Patient Disposition Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all the absolute criteria. Criteria for this component is as follows: Patient’s response to therapy Patient’s refusal If patient is refusing transport, the chart should reflect: Complete patient assessment, PMHx, etc. What means taken to convince the patient to allow transport to the hospital Instructions given to the patient, possible complications, etc. Signed patient refusal form Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: If the patient’s condition does not change during transport, Document as no change in patient’s condition. If patient is being transported to the hospital by alternate means, state so in narrative (e.g. pt. going by alternate means). Revision Date 7/23/2010 114 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 115 TOC Differential/ICD-9 Code Standard: An evaluation of “satisfactory” completion of this documentation component shall require proper documentation of all of the absolute criteria. Criteria for this component is as follows: The EMS provider should indicate in the Diagnosis screen and ICD-9 Code of the EMS report an assessment of what s/he believes to be wrong with the patient. Goal: Proper documentation of 100% of the above criteria. Acceptable Terminology: This assessment may be in the form of a differential or a set of differentials. Unless there is absolutely no doubt as to the patient’s acute diagnosis, the EMS provider should avoid putting his/her differential in absolute terms (e.g. AMI) and should instead use more general terminology (e.g. Possible AMI or abdominal pain-unknown etiology) Avoid using R/O or Rule Out when stating your differential assessment. Doctors use this terminology when developing a series of tests to confirm their diagnosis. The EMS provider should avoid simply putting the patient’s chief omplaint as his/her assessment: Do not use Shortness of Breath, instead using something more definitive (e.g. Possible pulmonary edema secondary to CHF.) The charted differential should reflect which protocol(s) were used to manage the patient. Abbreviations Acceptable Terminology: See Appendix for a list of accepted medical abbreviations according to Medicare. Documentation of patient refusals should include the following additional information: • Pt/guardian has metal capacity to make informed decision as to consent/refusal • Aid/transport was necessary • Aid/transport was offered • Pt’s response to offer of aid/transport • Consequences of refusal clearly explained to patient or guardian Revision Date 7/23/2010 115 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines • • • • • DOCUMENTATION STANDARDS CG 42 Page 116 TOC Pt/guardian understands consequences of refusal Pt/guardian still refuses aid/transport after being informed of consequences Signature of patient/witness Disposition of patient upon release Pt advised to call EMS back at any time if condition changes or they change their mind “No Patient” or “No Sick or Injured” In order for an EMS unit to clear with "no patient" or "no sick or injured", the following criteria should be met: • The patient should have left the scene prior to EMS arrival, OR • The call itself should have been false (no such incident) OR • The people or person in question should deny ANY physical complaint to the EMS personnel's direct questioning AND • The EMS personnel should not be able to visualize ANY injury or evidence of injury or illness AND • The people or person should appear competent to make such an assessment of themselves. If the patient is the individual who actually called for or requested the ambulance, a “no patient” designation cannot be employed. Such a patient should have a refusal executed, as described previously in this policy. Documentation EMS shall document all demographic and operational information as outlined in the "Documentation Requirements" policy. EMS shall clearly document that the above criteria were present. The term Assist Only is used for lift assist or moving assistance of a person only. Any statement of chief complaint either to personnel on scene or to the communicator in Dispatch requires a complete refusal document or complete patient care report should be obtained without exception. A patient who has fallen may not be treated as an assist. All fall victims must be either transported or documented as a patient refusal. An assist call occurs when an individual requires aid in completing a task but does not have a medical emergency. Examples might include help getting from their bed into a wheelchair or from a vehicle into a residence. Upon arrival the crew should investigate the reason why the response was initiated and determine if the caller has a medical emergency. A good example might be the “caller” cannot get from the bed to the restroom. You should ask if this is normal for the patient or what prohibits the “caller” from accomplishing the task. Do they get short of breath? Are they unsteady on their feet or have dizziness when they get up? DO NOT ASSUME that assists calls may not require medical treatment and transport. Revision Date 7/23/2010 116 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DOCUMENTATION STANDARDS CG 42 Page 117 TOC As a pre-hospital care provider you should assess the condition of the individual requiring assistance- and if indicated –offer care, treatment and transport. If you have indications that a medical condition exists and the “caller” refuses transport a patient refusal should be obtained. This includes a complete set of vital signs and appropriate documentation of the assessment as well as any instructions you gave the “caller”. After you have determined it is truly an assist call and not a medical emergency the documentation should include the following information: 1. 2. 3. 4. 5. 6. 7. Required operational information Name, address and phone number of person requesting assistance. The exact reason you were called for the assist documented in the narrative. How you concluded that a medical emergency did not exist. What actions were performed or what assistance was provided. Disposition of the person requesting assistance. Patient Assessment Revision Date 7/23/2010 117 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines NEW EMPLOYEE ORIENTATION PROGRAM CG 43 Page 118 TOC New Employee Orientation Program (nEop) The purpose of the MCHD EMS New Employee Orientation Program is to provide new employees the opportunity to become acquainted with policies and procedures as well as promote a team approach to patient care for the citizens and visitors of Montgomery County. General Information Each employee should receive the appropriate paperwork, including copies of the current Clinical Guidelines, Medication References, Medical Procedures currently performed by MCHD field staff as well as Clinical and Operations Policies & Procedures. This packet should also include paperwork to be completed by the Field Training Officer. The Professional Development Coordinator monitors the New Employee Orientation Program. All paperwork pertaining to evaluations and patient care documentation is to be faxed or delivered to the Office of the Medical Director at the end of each shift. In addition to furnishing copies of this paperwork to the Office of the Medical Director the employee should maintain the original. The initial orientation consists of three weeks of classroom instruction that may include organizational history and structure, employee benefits, patient care reporting and field software training, introduction to the driver-trainer program, as well as Clinical and Operations Policies and Procedures. Additional topics covered in the remainder of the week include, but are not limited to: introduction to the Road Safety Programs currently in use by MCHD, as well as DISC, 12-Lead class, Trauma Airway & Pain Management, and Territory Overview. New employees are required to ride a minimum of six (6) 24-hour shifts (or equivalent hours) with an FTO. After completion of these shifts the employee should be evaluated for competency at the attendant level and a recommendation should be made by the FTO to release the employee or continue the evaluation process. Once the employee is released the Assistant Director EMS-Operations should assign him/her a schedule. If the recommendation is made to extend the orientation, the employee may be assigned to another FTO with a written plan identifying specific areas of improvement. The employee will be re-evaluated at the end of two (2) 24-hour shifts (or equivalent time). At that time a recommendation may be made by the Office of the Medical Director to continue the process or terminate the employee. In addition to the above six (6) shifts, the new employee should schedule one (1) 12-hour shift with a Supervisor, a 10 hour shift with the courier, and complete six (6) hours as an observer in the communications center. Additionally, all new employees SHOULD pass a Policy & Procedures Manual (Clinical and Operations) test, an SDO test to their level of authorization and a territory test. Passing scores on these exams are 80%. The employee will not be released at the attendant level until these requirements have been completed. All new employees have a 90-day probationary period. If clinical or operations issues arise that result in counseling or disciplinary action the probation may be extended at the Revision Date 03/28/2011 118 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines NEW EMPLOYEE ORIENTATION PROGRAM CG 43 Page 119 TOC discretion of the Office of the Medical Director and/or Assistant Director EMS-Operations. Documentation will be placed in the employees’ file describing the reason for the extended probationary period and what requirements should be fulfilled by the employee as well as management for successful completion. Paramedics with previous experience as the lead medic on an MICU in a 9-1-1 setting may be considered for the In-Charge Evaluation Program. Entrance into this program requires successful completion of the nEop training at the attendant level as well as the 90-day probationary period. (See In-Charge Evaluation Program policy). Revision Date 03/28/2011 119 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CARD COURSES AND EDUCATIONAL OPPORTUNITIES CG 44 Page 120 TOC MCHD offers many card courses for our employees, some of which are required. These courses are offered several times throughout the year and are free to MCHD employees. It is the employee’s responsibility to maintain current certifications. Note: Since all card courses are offered by MCHD, employees who attend classes elsewhere are not reimbursed for the cost of the course. CPR is required for all field personnel. CPR, ACLS and BTLS are required for attendant EMT-P. CPR, ACLS, BTLS and PALS are required for In-Charge paramedics. In the event certification expires, the employee will be granted temporary authorization for a period not to exceed 2 years from expiration of the certification course. Expiration may impact promotional processes. This policy in no way supersedes requirement by TDSHS and/or National Registry for renewal of credential via continuing education. If, at the end of 2 years (temporary authorization) the employee has not provided proof of current certification, the employee may be subject to de-authorization, suspension or termination. COURSE ATTENDANCE When taking advantage of a class being offered by MCHD EMS, the employee should request a place in the class in writing. The class coordinator should make verification of placement. If cancellation is necessary it should be done within 48 hours of the scheduled class time. All attempts to cancel should be done through the coordinator of the class. If the employee fails to attend the class without prior cancellation, a written notification will be sent to the employee and a copy of that notification will be placed in the employee’s personnel file. After such an occurrence the employee may be asked to put up a deposit on any further classes. This deposit should be returned upon completion of the class. As with anything there may be exceptions to the above. Those situations will be considered on a case by case basis. INSTRUCTOR REQUIREMENTS MCHD EMS offers many teaching opportunities to those employees who are or wish to be instructors. In order to offer quality education to our employees as well as our community it is necessary to establish guidelines for our Instructors. The requirements necessary to maintain Instructor status with MCHD are to teach a minimum of two classes per year in each Instructor certification area. Revision Date 11/10/2005 120 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CARD COURSES AND EDUCATIONAL OPPORTUNITIES CG 44 Page 121 TOC Instructors will not be required to attend provider courses for those card courses in which they are MCHD EMS instructors, providing they maintain current Instructor certifications. Cancellation of a teaching assignment should be done no less than one week prior to the scheduled class. If cancellation occurs less than one week prior to class time, the Instructor is responsible for finding an equivalent replacement. If a replacement is not found by the Instructor, a written notification of the infraction will be sent to the Instructor with a copy being placed in their personnel file. If it occurs a second time, instructing privileges as well as its rewards may be revoked. INSTRUCTOR CRITERIA For those employees interested in becoming Instructors the following requirements are necessary: CPR INSTRUCTOR Current CPR certification Score of 90% or greater on CPR examination Attendance in a CPR instructor course Monitored during at least one class Final appointment of instructor status is the decision of the Education Department ACLS INSTRUCTOR EMT-P, RN, MD CPR-I or EMS-I Current ACLS certification Score of 90% on ACLS examination Attendance in an ACLS instructor course Monitored during at least one class Final appointment of instructor status is the decision of the Education Department PALS INSTRUCTOR EMT-P, RN, MD CPR-I or EMS-I Current PALS certification Score of 90% or greater on PALS examination Attendance in a PALS instructor course Monitored during at least one class Final appointment of instructor status is the decision of the Education Department Revision Date 11/10/2005 121 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CARD COURSES AND EDUCATIONAL OPPORTUNITIES CG 44 Page 122 TOC BTLS INSTRUCTOR EMT – EMT-P, RN, MD CPR-I or EMS-I Current BTLS certification IP in last BTLS class Attendance in a BTLS instructor course Monitored during at least one class Final appointment of instructor status is the decision of the Education Department EQUIPMENT AND RESOURCES MATERIALS MCHD EMS has purchased equipment and resource materials in an effort to provide as many educational opportunities as possible for its Employees. These resources are available to each employee. When requesting resource materials (books, software, etc.) please see the Clinical Department Clerk for the proper forms. When requesting equipment, please see the Education Specialist. This equipment shouldbe checked out for clinical practice or to instruct classes for MCHD EMS. When instructing for outside entities, use of MCHD EMS equipment requires approval by the Clinical Department. Revision Date 11/10/2005 122 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines RECERTIFICATION AND UPGRADE IN CERTIFICATION CG 45 Page 123 TOC Employees recertifying their Texas Department of State Health Services certification through examination should have scored a minimum of 70% on their National Registry Examination and provide the Clinical Department with a copy of their Texas Department of State Health Services certification. Upgrading Authorization In order for an employee to upgrade his/her certification from EMT to EMT-Intermediate or EMT-Intermediate to EMT-Paramedic, he/she should provide the Clinical Department with a copy of the new TDSHS certification and test scores. If a deficiency is detected on one or more subscales, a Personal Improvement Plan should be developed for the individual that should outline a remediation plan to correct the deficiency. As a final step, the employee is expected to successfully complete a protocol exam at the new level of certification to verify a firm understanding of the clinical practices of MCHD EMS. Authorization is separate from certification. Every provider should have a current certification. The Medical Director is responsible for granting authorization. Authorization is required to provide pre-hospital or out-of-hospital care to any patient within the South Texas Medical Control System. Certification level does not necessarily dictate authorization level. The Medical Director may authorize any provider to function at any level as per TDH Rule 157.11 AT NO TIME prior to receipt of the Letter of Authorization will the employee be permitted to perform any procedure or treatment modality which is reserved for the new level of authorization as outlined in the protocols. This may be considered practicing beyond the scope of his authorization, and may be considered to be a termination offense, and one that is reportable to Texas Department of State Health Services. Upon successful completion of these steps, a letter of authorization will be placed in the employee’s file. Only when the authorization process is complete, paperwork be submitted to Human Resources for consideration of potential wage increase. Revision Date 11/10/2005 123 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CONTINUOUS QUALITY IMPROVEMENT (CQI) CG 46 Page 124 TOC Total Quality Management Although Quality Improvement (QI) is relatively new to pre-hospital emergency medicine, Montgomery County Hospital District embraces the opportunity to continuously monitor and improve the standards that have been established by MCHD for the delivery of pre-hospital health care. Furthermore, MCHD believes that all employees want to do the best they can for every patient and should provide a high level of pre-hospital care to every patient they encounter as long as the following are intact: • The acceptable standard of care as well as employee performance expectations are clearly defined and measurable AND • The employee/s are provided adequate and appropriate equipment and/or tools to adhere to MCHD standards Quality Improvement is a non-punitive process designed to provide opportunities for personal and/or professional growth for the individual as well as the agency. Additionally, Quality Improvement within the MCHD system is established upon the principles of raising standards in all departments - patient care, vehicle maintenance, communications, operations and clinical, as well as billing and community outreach programs. This approach to QI relies upon the participation of all MCHD employees to be successful. Quality Improvement within the MCHD system is based on the following components: 1. Training and education of all levels of field personnel, directed at documented needs. 2. Assessment and evaluation of all patient-care oriented activities. 3. Involving all levels of personnel in establishing and ensuring the standard of care, protocols, procedures, and the assessment of care. 4. Effective hiring and selection process, orientation and training procedures, and evaluation of new personnel. 5. Effective training procedures and evaluation of In-Charge Evaluation candidates. 6. Establish regular review of patient-care-oriented standards, protocols, and evaluation systems. The goals of the clinical QI program are to: 1. Continuously and accurately evaluate the patient care oriented activities of all the EMS personnel in the system. 2. Continuously and accurately evaluate the operational, administrative, and procedural activities of our system as they relate to the delivery of patient care. 3. Accurately determine the training and educational needs of both individual EMS providers and the EMS system as a whole. 4. Provide continuous training and education to our providers which addresses their actual training and educational needs. 5. Identify and address areas of potential improvement in our system in all areas of patient care and operation. Revision Date 11/10/2005 124 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CONTINUOUS QUALITY IMPROVEMENT (CQI) CG 46 Page 125 TOC 6. Respond to complaints or concerns from both outside and inside the system about patient care or related activities in a timely and satisfactory manner. 7. Regularly evaluate and re-evaluate protocols, procedures, and patient care standards, and improve and update them as needed. 8. Allow the field personnel at all levels to actively influence the system’s operations as they relate to patient care. 9. Provide organizational management and administration with an accurate assessment tool for evaluating employee’s performance in patient care related activities. This approach to a successful QI program requires that MCHD make and maintain a commitment to continuous evaluation and improvement focused on response to such evaluations. The following are critical to the success of the program: 1. Utilization of objective assessment criteria. 2. Assessment of methods of patient care by comparing documented and observed clinical care to established criteria. 3. Utilization of appropriate methods to solve the identified problem with the focus being on improving individuals as well as the service as a whole. 4. Reassessment of the problem area identified to ensure that the problem has, in fact, been corrected. Critical QI functions extending beyond routine evaluation of field clinical performance and clinical care include: 1. An interface with continuing education that the findings of the QI process contribute materially to the content of the continuing education program. 2. Evaluation of on-line medical consults. 3. Incident investigations. The above items are accomplished from a proper mixture of the following: 1. Prospective: defined as actions that take place prior to the actual patient encounter (i.e. education, continuing education, development of stand delegated orders, medication and supply inventory requirements, etc). 2. Intermediate: evaluation of medical consults, on-scene evaluations by a preceptor or Supervisor, or scenario/realism training. 3. Retrospective: consisting of clinical chart audits for documentation and treatment as well as accurate and complete performance evaluations of each employee. If an audit (chart or field) finds no procedural or clinical exceptions, an audit report shall be filed as support evidence of the employees’ performance for inclusion in the annual performance appraisal. If an audit (chart or field) finds clinical exceptions, then copies and the audit report should be reviewed by the Medical Director, thus beginning the exercise of problem solving. The Medical Director or his/her designee should consider the following minimum factors during his/her review of the case: 1. Was the exception a system failure? Revision Date 11/10/2005 125 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CONTINUOUS QUALITY IMPROVEMENT (CQI) CG 46 Page 126 TOC 2. Were there extenuating circumstances on scene or enroute that contributed to the situation? 3. Did lack of training contribute to the situation? 4. Did the treatment and/or procedure cause permanent harm or injury to the patient? 5. Was the treatment and/or procedure performed appropriate for the patients illness/injury? 6. Was the employee authorized to provide the treatment and/or procedure performed? Once the factors and principles have been identified, the administrative staff should carry out action and/or training as recommended by the Medical Director. Each investigation is conducted on a case-by-case basis with consideration given to each of the previously listed items. Revision Date 11/10/2005 126 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines HANDLING CHILD AND ELDERLY ABUSE AND NEGLECT CG 47 Page 127 TOC General Information State law requires all professionals to report suspected cases of abuse (Texas Family Code § 261.101). Therefore, all employees are required to report actual and suspected cases of abuse. However, it is not the responsibility of MCHD EMS personnel to confront and attempt to remediate abusive situations. When abuse is suspected, provide all assessment and treatment as indicated. Attempt to persuade the patient to be transported to the hospital regardless of the severity of the injuries. Transport Situations – Upon arrival at the emergency room, privately and discreetly advise the nurse and/or physician of your suspicions. Non-transport Situations – If transport is refused, leave the scene and request to meet with law enforcement and a Supervisor to meet at a near by location. When law enforcement and the Supervisor arrive, advise them of your suspicions. In either situation Child Protective Services or Adult Protective Services should be contacted by the MCHD employee(s) responding to the call and or witnessing the event. Documentation In all cases, employees should include a detailed assessment of the actual or suspected abuse situation in the patient’s report. The assessment should describe the patient’s condition, emotional state, and the surrounding environment. Also, employees should include details in the patient’s report concerning the circumstances that created their suspicions of abuse and the employees’ actions. The appropriate agency should be contacted within 24 hours after the employee witnesses the actual or suspected abuse. Child and Elderly Abuse should be reported to Adult Protective Services (AS) or Child Protective Services (CPS): 1-800-252-5400 or https://www.txabusehotline.org Revision Date 11/10/2005 127 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines CARE AND TRANSPORTATION OF MINORS CG 48 Page 128 TOC Minors may only receive the treatment necessary to preserve life and prevent further injury in the absence of a consenting parent, guardian, or adult family member. Parents and guardians retain the right to consent to and refuse treatment for minors in their charge who are under eighteen (18) years of age unless the minor qualifies to consent to treatment. When a minor’s parent(s) or guardian(s) refuse treatment for the minor, MCHD-EMS personnel should not force any treatment but shall encourage treatment or recommend that the minor patient be transported to a hospital. If a minor’s life is endangered by the parent’s or guardian’s refusal for treatment, or if personal abuse is suspected, the supervising Emergency Department physician shall be notified immediately and his or her instructions followed. MCHD-EMS personnel are required by law to report all cases of suspected abuse. Refer to the MCHD-EMS Field Operations Guidelines concerning Child Abuse for further guidance. Married Minors Married minors reserve the right to consent to or refuse treatment. Unmarried, Pregnant Minors Unmarried, pregnant minors may consent to or refuse treatment for pregnancy-related conditions only, treatment for other conditions require parental consent or refusal of treatment. Abandoned Children Section 262.301 of the Texas Family Code, as amended, requires MCHD-EMS personnel, without a court order, to take possession of a child who is thirty (30) days old or younger if the child is voluntarily delivered to the employee by the child’s parent and the parent did not express an intent to return for the child. A MCHD-EMS employee who takes possession of a child under these circumstances shall perform any act necessary to protect the physical health or safety of the child. The employee should notify his or her Supervisor of the situation as soon as possible. Revision Date 11/10/2005 128 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DEPARTMENT OF STATE HEALTH MINIMUM INVENTORY LIST CG 49 Page 129 TOC Airway and Oxygen Supplies Amount Airway and Oxygen Supplies Amount Oropharyngeal Airways (5 total) Nasopharyngeal Airways (6 total) BVM Adult, Child, Neonate PEEP Valve Nasal Cannula Non-Rebreather Mask Pedi Face Mask Infant Face Mask Oxygen Tubing 1 set 1 set 1 ea 1 2 2 2 1 1 Vent Circuit Tubing Lidocaine Jelly KY Jelly Laryngoscope Handle Mac Blades #1,3,4 Miller Blades #0,1,3,4 Magill Forceps Adult, Pedi Bulb Syringe SpO2 Sensor 1 1 4 1 1 ea 1 ea 1 ea 1 1 ea Adult Nitronox Mask Pedi Nitronox Mask Nebulizer Nebulizer Mask Adult Nebulizer Mask Pedi Endotracheal Tube 2.0 - 8.5 Endotracheal Tube Securing Device 1 1 1 1 1 1 ea 1 NG Tube Rigid Suction Catheter with tubing Suction Catheters 6, 8, 10, 14, 18fr 60 cc Syringe with Cath Tip On Board suction and liner/canister Portable Suction Unit On Board O2 Cylinder with Regulator 1 1 1 ea 1 1 1 1 Tube Check Bulb 1 Spare Portable O2 Cylinder 1 ET Introducer 1 Portable O2 Cylinder with Regulator 1 Stylette #11 Scalpel 1 1 Ohio Wall Adaptor Portable Ventilator with Ohio Adapter 1 1 O2 "Christmas Tree" Pneumothorax Kit Portable O2 Key IV Equipment 0.9% NaCl IV fluid (500 or 1,000 ml) 0.9% NaCl IV fluid (100 ml) IV Start Kit 5” extension Alcohol Swabs/Chlorohexidine 10 gtt/ml Primary IV Set 60 gtt/ml Primary IV Set Buretrol IV Set 1 cc Syringe 3 cc Syringe 5 cc Syringe 10 cc Syringe 20 cc Syringe 30 cc Syringe Revision Date 08/6/2012 1 1 1 Amount 4 1 4 3 15 3 2 1 2 4 3 2 1 1 Nitronox with Ohio Adapter ETCO2 filterline Combitube IV Equipment Intraosseous Needle EZ IO Driver Vial Access Cannula 10cc 0.9%NaCl Flush Tubex Injector 18 ga Needle 22 ga Needle 25 ga Needle 14 ga IV Catheter 16 ga IV Catheter 18 ga IV Catheter 20 ga IV Catheter 22 ga IV Catheter 24 ga IV Catheter 1 1 ea 1 Amount 1 1 ea 4 4 1 5 1 1 1 1 3 3 1 1 129 Montgomery County Hospital District-EMS DEPARTMENT OF STATE HEALTH MINIMUM INVENTORY LIST Clinical Guidelines – Clinical Guidelines CG 49 Page 130 TOC Medications Acetaminophen Elixir Activated Charcoal Adenosine Albuterol** Amiodarone Atropine Sulfate 1mg/10ml Atropine Sulfate Multi-dose 8mg/20ml Baby Aspirin Calcium Gluconate Diltiazem Dextrose 25% Dextrose 50% Diphenhydramine Dopamine pre-mix Epinephrine 1:1,000 Epinephrine 1:1,000 Epinephrine 1:10,000 Etomidate* Fentanyl* Glucagon Monitoring Devices Monitor/Defibrillator with cables ECG Electrodes ECG Paper Defib/Pacer Pads (adult) Defib/Pacer Pads (pedi) Prep Razor Spare Monitor Battery Thermometer 8mg 324mg 4.65mEq 100mg 2.5g 25g 50mg 400mg 1mg 1 4mg 20mg 100mcg 1mg Amount 1 10 1 1 1 1 1 1 BLS Equipment Kerlex Triangular Bandages Bandaids Cold Packs Heat Packs Tape 3" Tape 1" 4x4 Sterile Tubs Amount 2 3 5 3 3 1 1 4 Revision Date 08/6/2012 Amount 975mg 50g 24mg 2.5mg 450mg 4 Medications Ketamine* Labetalol Lidocaine 2% Lidocaine pre-mix Magnesium Sulfate Amount 250mg 10mg 100mg 4g 2g Naloxone 6mg Nitroglycerin SL Oral Glucose Promethazine Sodium Bicarbonate 4.2% Sodium Bicarbonate 8.4% Methylprednisolone Succinylcholine Thiamine Diazepam* Vasopressin Vecuronium Midazolam* Levalbuterol 0.63 mg/3ml** Levalbuterol 1.25mg/3ml** Monitoring Devices BP Cuff Adult BP Cuff Large Adult BP Cuff Thigh Cuff BP Cuff Child BP Cuff Infant Stethoscope Lancets Glucometer Glucometer Test Strips BLS Equipment 4x4 Nonsterile Loaf Triage Tags OB Kit Sterile Saline/Water for irrigation Disposable Rescue Blanket KED Traction Splint (adult/pedi) ABD pads 1 bottle 15g 25mg 5mEq 50mEq 125mg 200mg 100mg 10mg 40units 10mg 5mg 1.89mg 3.75mg Amount 1 1 1 1 1 1 5 1 1 Amount 1/2 loaf 5 1 1 1 1 1 ea 2 130 Montgomery County Hospital District-EMS Clinical Guidelines – Clinical Guidelines DEPARTMENT OF STATE HEALTH MINIMUM INVENTORY LIST CG 49 Page 131 TOC BLS Equipment Multi-trauma dressings Adaptic Dressings Burn Sheets Trauma Shears Disposable Head Immobilizer Webbing Miscellaneous Equipment Stretcher/stretcher mount Penlight Towels Whisk broom Fitted Sheets Disinfectant/cleaning solution Gloves X-small Gloves Small Gloves Medium Gloves Large Gloves X-large Hand Cleaner Gel Safety Glasses Emesis Bags Amount 1 2 1 1 2 2 Amount 1 1 2 1 2 1 1 box 1 box 1 box 1 box 1 box 1 3 1 BLS Equipment Flexible splint Backboard Scoop Stretcher Multi-size C-Collar Adult Multi-size C-Collar Pedi Safety Glasses Miscellaneous Equipment Hepa Masks Personal Protection Packs Small Sharps Container Medium Sharps Container Biohazard Bag Traffic Triangle Set EMS Safety vests Flashlight Fire Extinguisher Montgomery County Key Map No Smoking Signs Two-way radio Hazardous Materials Quick Ref. Inventory Lists Toughbook or clipboard with reports SDO Manual Broselow Tape *Required when available. Not required if limited by national backorder/shortage **Albuterol may be used interchangeably with Levalbuterol Amount 2 1 1 2 2 2 Amount 2 2 1 1 1 bag 1 2 1 1 1 2 1 1 1 1 1 1 March 31, 2014. Revision Date 08/6/2012 131 ADULT BEHAVIORAL This Page Intentionally Left Blank Montgomery County Hospital District-EMS Policy and Procedure Manual – Adult Behavioral BEHAVIORAL ASSESSMENT AB 01 Page 134 TOC Criteria and History :   Historical Findings: - PMHx of psychiatric problems - Use of psychiatric medications - Substance abuse Physical Findings: - Altered mental status - Evidence of trauma - Fear, anger, confusion, or hostility Assessment: Glascow Coma Scale         Determine that the scene is safe before entering GCS C.A.B.C. Secondary Assessment Vital signs Blood glucose Pertinent PMHx - Does the patient have previous suicide attempts or ideations? - Is the patient under care of a psychologist / psychiatrist? - Is the patient cared for by others or self-reliant? SUBECT IN CUSTODY RISK ASSESSMENT SCALE (SICRAS) Eye Response Verbal Response Motor Response 4 Spontaneous 5 Orientated 6 Obeys 3 To verbal 4 Confused 5 Localizes 2 To pain 3 Inappropriate 4 Withdraws 1 No response 2 Incomprehensible 1 No response 3 Flexion 2 Extension 1 No response Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 134 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Behavioral ABUSE / NEGLECT AB 02 Page 135 TOC Criteria and History :  Historical Findings: - Recent events  Physical Findings: - Contusions at different healing stages - Malnourished appearance - Withdrawn Assessment:  Behavioral Assessment Primary Interventions:    Apply pressure to any hemorrhage O2 via most appropriate method Spinal Motion Restriction, if indicated Secondary Interventions:    Bandaging / splinting Vascular Access Report abuse to APS  C-spine clearance, if indicated Contact information for APS: 1-800-252-5400 or https://www.txabusehotline.org Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 135 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Behavioral AGGRESSIVE / VIOLENT BEHAVIOR AB 03 Page 136 TOC Criteria and History :  Historical Findings: - Known violence - Aggression  Physical Findings: - Agitation - Offensive posture - Combative - Hallucinations Assessment:      Behavioral Assessment Evaluate patient mental status also obtain BG This procedure applies to patients being treated under implied consent and is not to be used on patients specifically refusing transport. Have sedative medications prepared for injection. Prepare for possible hypotension or CNS depression side effects. If possible, inquire about medication allergies Primary Interventions:  Reassure patient  soft restraints if patient is physically harmful  O2 via most appropriate method  Spinal Motion Restriction, if indicated Secondary Interventions:  Vascular Access: Obtain as soon as possible after Patient Safety Sedation medications have been administered IM. If patient condition changes refer to appropriate protocol Consult: required before sedation is attempted. Exception--imminent threat to personnel which may pose immediate physical injury to crew.    Ketamine 2-4 mg/kg IM or IV may repeat q 10 minutes if sedation inadequate Midazolam 2 mg IV/IM/IO as needed to prevent emergence reaction Atropine 0.1 to 0.5 mg IM single dose only to prevent hypersalivation Do not Repeat Continuous ECG, SpO2, blood pressure monitoring q 5 minutes after sedation Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 07/26/2010 136 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Behavioral ANXIETY / EMOTIONAL DISTRESS AB 04 Page 137 TOC Criteria and History :   Historical Findings: - History of Recent Traumatic Event - Post Trauma Stress Disorder Physical Findings: - Agitation - Hyperventilation - Hallucinations Assessment:  Behavioral Assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:  Vascular Access    Midazolam 2 – 10 mg IV/IM/IO Diazepam 2 – 10 mg IV/IO C-spine clearance, if indicated Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 137 ADULT CARDIAC This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac Criteria and History:  Historical Findings: - Preceding Symptoms - CPR and/or Treatment PTA - PMHx - Elderly, female, diabetic  Physical Findings: - Altered mental status - Slow, fast or absent pulse - Irregular pulse - Dyspnea/Apnea - Chest pain/Palpitations - Diaphoresis - Pale, ashen or mottled skin Assessment:  C. A. B. C.  Secondary Assessment  Vital Signs  ECG 3-Lead and 12-Lead - Right sided 12-Lead if indicated  Blood glucose  Lung sounds  GCS  Retavase inclusion/exclusion criteria  OPQRST  ASPN  SAMPLE - Include history of Viagra, Levitra, Cialis, or similar medications within last 48 hours (Do not Administer NTG) CARDIAC ASSESSMENT AC 01 Page 140 TOC Fibrinolytic Inclusion/Exclusion Checklist Inclusion - 18 years or older - Ischemic discomfort 30 minutes – 12 hours - ST Elevation > 1mm in 2 or more contiguous limb leads or > 2mm in contiguous precordial leads - Presumed new LBBB Exclusion - Hx of CVA or TIA - Intracranial neoplasms, aneurysm - Recent surgery or trauma, or active internal hemorrhage - B/P > 180/110 - Cardiogenic shock/ PE with intubation - Use of oral anticoagulants within 3 days - Suspected AAA - Use of cocaine or amphetamines within 3 days - Pregnancy Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 140 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac ACUTE CORONARY SYNDROME / AMI AC 02 Page 141 TOC Criteria and History :   Historical Findings: - Medical etiology Physical Findings: - Chest discomfort - Back, shoulder, neck, jaw, epigastric discomfort - Discomfort suggestive of AMI with associated symptoms: dyspnea, nausea, diaphoresis, weakness Assessment:   Cardiac Assessment Transmit 12-Lead to receiving facility from land line or stationary vehicle Primary Interventions:       O2 via most appropriate method Vascular Access ASA 324 mg PO regardless of prior ASA use NTG 0.4 SL and/or NTG Paste 1” - Use with caution in Right-sided AMI - q 5 min x 3 prior to IV if B/P > 100 mmHg - Once IV established, NTG can be administered q 5 min if B/P >100 mmHg Right sided AMI - Fluid Bolus Fibrinolytic Inclusion/Exclusion checklist Nitroglycerin, in any form, is not to be administered to patients that have taken Viagra (Sildenafil citrate) or Levitra (Vardenafil HCl) within the last 24 hours. Nitroglycerin is not to be administered to patients who have taken Cialis (Tadalafil) within the last 48 hours. Fatal hypotension has been reported when Nitroglycerin or other Nitrates are given to patients who have used Viagra or Levitra in last 24 hours, and in patients who have used Cialis in the last 48 hours. If Right sided AMI is suspected, IV should be established prior to administration of NTG. Atropine should be used with caution in the setting of an ACS and should be avoided unless systolic BP is < 80 mmHg and/or heart rate <40 bpm Revision Date 01/26/2009 141 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac ACUTE CORONARY SYNDROME / AMI AC 02 Page 142 TOC Fibrinolytic Inclusion/Exclusion Checklist Inclusion - 18 years or older - Ischemic discomfort 30 minutes – 12 hours - ST Elevation > 1mm in 2 or more contiguous limb leads or > 2mm in contiguous precordial leads - Presumed new LBBB Exclusion - Hx of CVA or TIA - Intracranial neoplasms, aneurysm - Recent surgery or trauma, or active internal hemorrhage - B/P > 180/110 - Cardiogenic shock/ PE with intubation - Use of oral anticoagulants within 3 days - Suspected AAA - Use of cocaine or amphetamines within 3 days - Pregnancy Secondary Interventions:  Secondary Vascular Access  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM - May be repeated x 1 if N/V persists after 15 minutes  Pain Management Contraindications for Metoprolol Absolute: - Heart Rate < 60 bpm - Systolic Blood Pressure < 100 mmHg - 2nd and 3rd degree heart block - 1st degree heart block with PR interval > 0.24 sec - STEMI precipitated by cocaine use Relative: - Pregnancy – 2nd and 3rd trimester - Cardiogenic Shock - Active CHF - Active Asthma - COPD  Transport to appropriate facility Conroe Regional Medical Center Tomball Regional Medical Center Memorial Hermann – The Woodlands St. Luke’s – The Woodlands Consult with receiving physician for Retavase Consult:  Retavase 5 –10 unit bolus per physician order, repeated in 30 minutes if available Metoprolol 5 mg IV - Repeat q 5 minutes x 2 to a total of 15 mg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 142 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac ASYSTOLE AC 03 Page 143 TOC Criteria and History :    Historical Findings: - Medical etiology Physical Findings: - Unconscious - Pulseless - Agonal respirations; apnea ECG Findings: - Asystole confirmed in two or more leads  Determine if resuscitation is medically inappropriate - Normothermic rigor-mortis Injuries Incompatible with life Decomposition Lividity Pulseless, apneic patients in multiple casualty situations Proper DNR documentation Assessment: • Cardiac Assessment Perform at least 20 minutes of quality compressions (verified by CPR feedback device if available) prior to moving patient unless environment is unsuitable. Do not interrupt compressions for ALS procedures. Primary Interventions: ET Tube Confirmation:  Continuous CPR ∼ Confirm with 5 methods as  BVM Ventilation with high-flow O2 per procedure  Maintain airway with OPA Capnometry Reference: • Intubate ∼ EtCO2 readings consistently > 0 indicate tube is not in the • Pacing as soon as possible esophagus. Verify tube • Vascular Access placement is not right • Induce hypothermia if arrest continues > 5 minutes mainstem. In the cardiac • Vasopressin 40 units q 5 minutes if unrestricted vasopressin arrest, through quality CPR supply and controlled ventilation Or If restricted vasopressin supply attempt to maintain EtCO2 levels as close to 35 – 45 • Vasopressin 40 units initial dose then mmHg as possible. Values • Epinephrine 1:10,000 1 mg IV/IO or 2 mg ET repeat q 5 minutes under 15 mmHg indicate poor • May repeat Vasopressin 40 units at 20 minutes survivability. EtCO2 readings Or If Vasopressin unavailable of 0 mmHg after six breaths indicate an unsuccessful • Epinephrine 1:10,000 1 mg IV/IO or 2 mg ET repeat q 5 minutes intubation. Secondary Interventions: • • • • Naloxone 0.4 – 2 mg IV/IO/IN for respiratory depression due to suspected narcotic overdose repeat PRN based on patient response Sodium Bicarbonate 1 mEq/kg IV/IO #18 fr Nasogastric tube placement Calcium Gluconate 4.65 mEq 10 ml / 10% Solution IV/IO •  Consult: After 20 minutes of quality chest compressions refer to medical termination procedure Consider field termination if patient meets criteria per medical termination procedure Revision Date 11/21/2011 If you suspect acidosis, use Sodium Bicarbonate early in treatment plan. 143 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac BRADYCARDIA AC 04 Page 144 TOC Criteria and History :    Historical Findings: - Medical etiology Physical Findings: - Weak, dizzy - Chest pain - Pulmonary edema - AMS - Systolic blood pressure < 90 mmHg ECG Findings: - Any underlying cardiac rhythm or a ventricular rate < 60 bpm Assessment:  Cardiac Assessment Primary Interventions:   O2 via most appropriate method Vascular Access Secondary Interventions:    Consider Pacing Atropine 0.5 mg – 1mg IV/IO - q 3 – 5 min if beneficial response seen - Max dose of 0.04 mg/kg Midazolam 2 – 5 mg IV/IM/IO - For sedation prior to pacing Revision Date 11/01/2005 Bradycardia may be seen in the presence of AMI. You should treat the original pathology rather than the after-effect (MONA before Atropine) in most cases. High degree blocks with wide complexes will most likely respond to pacing. High degree blocks with narrow complexes may respond to atropine. 144 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac BRADYCARDIA AC 04 Page 145 TOC Consult:  Dopamine Infusion 5-20 mcg/kg/min - Use IV pump - Administer If patient remains hypotensive 5 minutes after fluid bolus Dopamine Chart (gtts/min) (400mg/250 ml Normal Saline) KGS 40 50 60 70 80 90 100 MCG/MIN 5 8 10 12 13 15 17 19 10 15 19 22 26 30 33 37 15 22 28 33 39 44 50 56 20 30 37 44 52 59 67 74 25 37 46 56 65 74 82 93 Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 145 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac CHF / PULMONARY EDEMA AC 05 Page 146 TOC Criteria and History :  Historical findings: - Prior history - Orthopnea - Acute difficult breathing at night  Physical Findings: - Dyspnea with auscultated findings of pulmonary edema - Systolic B/P > 90 mmHg  ECG Findings: - Atrial Fibrillation may be present Assessment:  Cardiac Assessment Obtain temperature to rule out pneumonia If patient is hemodynamically unstable, consider RVI or other causes Primary Interventions:   O2 via most appropriate method Vascular Access Secondary Interventions:    NTG 0.4 – 0.8 SL q 5 min x 3 prior to Vascular Access if B/P > 100 mmHg - Once vascular access established, NTG can be administered q 5 min if B/P >100 mmHg NTG Paste 1” CPAP 3 – 10 cmH2O  Consider need for RSI Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2012 146 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac HYPOTHERMIC INDUCED ARREST AC 06 Page 147 TOC Criteria and History :    Historical Findings: - Medical etiology Physical Findings: - Pulseless - Agonal respirations; apnea - Environmental evidence of hypothermia ECG Findings: - Any pulseless rhythm Assessment:   Cardiac Assessment Core Temperature Primary Interventions:      CPR - BVM ventilation with warm 100% O2 Humidified - ResQPOD - Maintain open airway OPA Intubation Vascular Access - Use warm fluid Warm patient - Remove wet clothing - Heat packs to arm pits and groins If V-Fib: - Biphasic defibrillation Defibrillation Reference - 1 defibrillation at 150j. ∼ Do not repeat defibrillation and do not medicate if temperature is below 85° F Remove ResQPOD if ROSC occurs immediately ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify the placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Secondary Interventions:  Refer to appropriate rhythm protocol for medication reference Revision Date 02/28/2011 147 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac NARROW COMPLEX TACHYCARDIA - STABLE AC 07 - A Page 148 TOC Criteria and History :  Historical Findings: - History of SVT/ use of Adenosine - History of A-Fib or A-Flutter or WPW  Physical Findings: - Systolic B/P > 90 mmHg - Chest pain with dyspnea, lethargy, dizziness, pulmonary edema, or AMS  ECG Findings: - Narrow Complex SVT (rate > 150 and QRS < 0.12 seconds) Assessment:  Cardiac Assessment Primary Interventions:   O2 via most appropriate method Vascular Access - Fluid Bolus if B/P is < 90 mmHg systolic Secondary Interventions:   Valsalva maneuver by patient Adenosine 12 mg RAPID IV/IO followed by 20 ml flush - May repeat x 1 as 12 mg RAPID IV/IO followed by 20 ml flush of NS  Diltiazem 10 – 20 mg IV - Followed by infusion of 80 – 90 mg at 5mg / hr  Amiodarone 150 mg IV/IO over 10 min - Use IV pump Mix 150 mg in 100 ml of NS Consult: Revision Date 06/21/2012 148 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac NARROW COMPLEX TACHYCARDIA - UNSTABLE AC 07 - B Page 149 TOC Criteria and History :  Historical Findings: - History of SVT/ use of Adenosine - History of A-Fib or A-Flutter  Physical Findings: - Systolic B/P < 90 mmHg and/or any of the following: • Chest pain • Dyspnea • Lethargy • Dizziness • Pulmonary edema • AMS  EKG Findings: - Narrow Complex SVT (rate > 150 and QRS < 0.12 seconds) Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Cardioversion  Midazolam 2 – 5 mg IV/IM/IO if patient condition allows  Vascular Access - Fluid Bolus if B/P is < 90 mmHg Secondary Interventions: Cardioversion reference: - 50 j - 70 j - 100 j - 150 j - 200 j  Adenosine 12 mg RAPID IV/IO followed by 20 ml flush - May repeat x 1 as 12 mg RAPID IV/IO followed by 20 ml flush of NS  Diltiazem 10 – 20 mg IV - Followed by infusion of 80 – 90 mg at 5 mg/hr  Amiodarone 150 mg IV/IO over 10 min - Use IV pump Mix 150 mg in 100 ml of NS Consult: Revision Date 02/28/2011 149 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac NON-TRAUMATIC CHEST PAIN AC 08 Page 150 TOC Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Chest discomfort - Back, shoulder, neck, jaw, epigastric discomfort  ECG Findings: - No evidence of ischemia or injury Assessment:  Cardiac Assessment Primary Interventions:   O2 via most appropriate method Vascular Access Secondary Interventions:     Ondansetron 4-8mg IV/IM/IO Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min Promethazine 12.5 mg IV/IO/IM - Must be diluted in 20 mg NS for IV/IO Administration - May be repeated x 1 if N/V persists after 15 minutes Pain Management Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 150 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac POST RESUSCITATION MGMT AC 09 Page 151 TOC Criteria and History :    Historical Findings: - Post cardiac arrest Physical Findings: - Patient with spontaneous circulation (palpable carotid/radial pulse) AFTER being treated for any non-perfusing rhythm ECG Findings: - Any perfusing rhythm Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Induce Hypothermia Secondary Interventions:  Amiodarone loading dose of 150 mg IV       over 10 min - Use IV pump - Mix 150 mg in 100 ml of NS - If ventricular rhythms Amiodarone infusion 1 mg/min - Use IV pump - Mix 150 mg in 100 ml of NS - If patient previously treated with Amiodarone for ventricular rhythms Lidocaine 1 – 1.5 mg/kg IV - If patient did not previously receive and converted from a ventricular rhythm WITHOUT bradycardia Lidocaine Infusion 2 – 4mg/min - Use IV pump - If patient received Lidocaine prior to ROSC Fluid Bolus Dopamine Infusion 5 – 20 mcg/kg/min - Use IV pump - Administer If patient remains hypotensive 5 minutes after fluid bolus Dopamine Chart (gtts/min) (400mg/250 ml Normal Saline) KGS 40 50 60 70 80 90 100 MCG/MIN 5 8 10 12 13 15 17 19 10 15 19 22 26 30 33 37 15 22 28 33 39 44 50 56 20 30 37 44 52 59 67 74 25 37 46 56 65 74 82 93 Remove ResQPOD if ROSC occurs immediately IF INDICATED  Amiodarone 150 mg over 10 minutes if no bolus was given.  Amiodarone 1 mg/min for a maintenance infusion. Control shivering with: - Midazolam 0.1 mg/kg IV/IO - Vecuronium 0.1 mg/kg IV/IO (Max 10 mg) (only if Midazolam does not control shivering) Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2010 151 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac PULSELESS ELECTRICAL ACTIVITY AC 10 Page 152 TOC Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Unconscious - Pulseless - Agonal; apnea  ECG Findings: - Pulseless rhythm; not V-fib, V-Tach, Asystole Assessment:  Cardiac Assessment Primary Interventions:  Continuous CPR  BVM Ventilation with high-flow O2  Maintain airway with OPA  Intubate • Vascular Access • Induce hypothermia if arrest continues > 5 minutes • Vasopressin 40 units q 5 minutes if unrestricted vasopressin supply Or If restricted vasopressin supply • Vasopressin 40 units initial dose then • Epinephrine 1:10,000 1 mg IV/IO or 2 mg ET repeat q 5 minutes • May repeat Vasopressin 40 units at 20 minutes OrIf Vasopressin unavailable • Epinephrine 1:10,000 1 mg IV/IO or 2 mg ET repeat q 5 minutes Secondary Interventions:   •    Chest Decompression if pneumothorax is present Fluid Bolus Naloxone 0.4 – 2 mg IV/IO/IN for respiratory depression due to suspected narcotic overdose Consider Pacing for heart rate < 60 Sodium Bicarbonate 1 mEq/kg IV/IO #18 fr Nasogastric tube placement Revision Date 11/21/2011 Perform at least 20 minutes of quality compressions (verified by CPR feedback device if available) prior to moving patient unless environment is unsuitable. Do not interrupt procedures. compressions for ALS ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tube placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Administer Epinephrine ET ONLY if NO IV/IO ACCESS Consider all other treatable causes - Hypoxia - ventilation - Hypothermia - warming - Hyperkalemia – calcium gluconate and sodium bicarbonate - Acidosis – ventilation and sodium bicarbonate - Massive MI – heart cath - Hypovolemia/hypotension – fluid replacement - Pulmonary embolism – surgery 152 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac  Calcium Gluconate 4.65 mEq 10 ml / 10% Solution IV/IO PULSELESS ELECTRICAL ACTIVITY AC 10 - Page 153 TOC Cardiac tamponade – pericardiocentisis Drug overdose - narcan Tension pneumothorax – chest decompression Consult: • After 20 minutes of quality chest compressions refer to medical termination procedure Revision Date 11/21/2011 153 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac VENTRICULAR ECTOPY AC 11 Page 154 TOC Criteria and History :    Historical Findings: - Medical etiology Physical Findings: - Chest pain with weakness, dizziness, dyspnea, irregular rhythm ECG Findings: - Six or more PVC’s per minute - Multiform PVC’s - Couplets, triplets - Evidence of AMI in the absence of bradycardia   Potential for the occurrence of R-on-T phenomenon If patient’s pulse is < 60 BPM, treat bradycardia first Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:  Amiodarone 150 mg IV over 10 min - Use IV pump - Mix 150 mg in 100 ml NS  Amiodarone infusion 1 mg/min - Use IV pump - Mix 150 mg in 100 ml NS  Lidocaine 1 mg/kg IV - q 5 minutes as 0.5 mg/kg up to 3 mg/kg total  Lidocaine Infusion 2 – 4 mg/min - Use IV pump - If successful conversion of the rhythm with lidocaine bolus Consult:  Magnesium Sulfate 1 – 2 g dilute in 10 ml of NS SLOW IV/IO Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 154 Montgomery County Hospital District-EMS VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA Clinical Guidelines – Adult Cardiac    Criteria and History : Historical Findings: - Medical etiology Physical Findings: - Unconscious - Pulseless - Agonal respiration; Apnea ECG Findings - V-Fib or Pulseless V-Tach Assessment:  Cardiac Assessment AC 12 Page 155 TOC Perform at least 20 minutes of quality compressions (verified by CPR feedback device if available) prior to moving patient unless environment is unsuitable. Do not interrupt compressions for ALS procedures. Consider all potential non-cardiac causes ∼ Remove False Teeth, Secretions, or any vomitus ∼ Primary Interventions: • • • • • • • • • • • • If witnessed, immediate defibrillation If arrest is not witnessed by responding unit Continuous chest compressions 1-2 minutes prior to defibrillation and medication BVM Ventilation with high-flow O2 Maintain airway with OPA Continuous CPR Deliver defibrillation q 2 minutes Intubate; respiratory rate 8 breaths per minute Vascular Access Induce hypothermia if arrest continues > 5 minutes Vasopressin 40 units q 5 minutes if unrestricted vasopressin supply Or If restricted vasopressin supply • Vasopressin 40 units initial dose, then • Epinephrine 1:10,000 1 mg IV/IO or 2 mg ET repeat q 5 minutes • Vasopressin 40 units at 20 minutes Or If Vasopressin unavailable • Epinephrine 1:10,000 1 mg IV/IO or 2 mg ET repeat q 5 minutes Amiodarone 300 mg IV/IO (Repeat 1x after 10 minutes with 150mg) Revision Date 06/21/2012 Defibrillation Reference Biphasic defibrillation at 150 j should be done during rotation of compressor to reduce hands off period After three 150 j shocks consider increasing to 200 j particularly if 150 j fails to terminate VF ET Tube Confirmation: Confirm with 5 methods as per procedure Capnometry Reference: EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tube placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Administer Epinephrine ET ONLY if NO IV/IO ACCESS 155 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR TACHYCARDIA AC 12 Page 156 TOC Secondary Interventions: • • • • • • Lidocaine 1.5 mg/kg IV/IO or 3 mg/kg ET Magnesium Sulfate 1 – 2g dilute in 10 ml of NS SLOW IV/IO Sodium Bicarbonate 1 mEq/kg IV/IO Calcium Gluconate 4.65 mEq 10 ml / 10% Solution IV/IO Naloxone 0.4 mg – 2 mg IV/IO/IN for respiratory depression due to suspected narcotic overdose #18 fr Nasogastric tube placement Revision Date 06/21/2012 ∼ Only Administer Magnesium Sulfate with: • Refractory V-Fib • Torsades Des Pointes ∼ Naloxone for suspected Drug Overdose ∼ Sodium Bicarbonate for Acidosis and TCA overdose ∼ Calcium Gluconate for Renal Dialysis Patients or suspected hyperkalemia 156 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac WIDE COMPLEX TACHYCARDIA - STABLE AC 13 - A Page 157 TOC Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Hemodynamically stable - Palpitations  ECG Findings: - Ventricular Tachycardia, Wide Complex (QRS > 0.12 seconds) Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:  Amiodarone 150 mg IV/IO over 10 min - Use IV pump - Mix 150 mg in 100 ml NS  Amiodarone infusion 1 mg/min - Use IV pump - Mix 150 mg in 100 ml NS  Lidocaine 1 mg/kg IV/IO - q 5 minutes as 0.5 mg/kg up to 3 mg/kg total  Lidocaine Infusion 2 – 4 mg/min - Use IV pump - If successful conversion of the rhythm with lidocaine bolus  Magnesium Sulfate 1 – 2 g dilute in 10 ml of NS SLOW IV/IO Consult: Revision Date 02/28/2011 157 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Cardiac WIDE COMPLEX TACHYCARDIA - UNSTABLE AC 13 - B Page 158 TOC Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Systolic B/P < 90 mmHg and/or any of the following: • Chest pain • Dyspnea • Lethargy • Dizziness • Pulmonary edema • AMS  ECG Findings: - Ventricular Tachycardia, Wide Complex (QRS > 0.12 seconds) Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Midazolam 2 – 5 mg IV/IM/IO - For sedation prior to cardioversion  Synchronized Cardioversion - 50 j - 70 j - 100 j - 150 j Secondary Interventions:  Amiodarone 150 mg IV over 10 min - Use IV pump - Mix 150 mg in 100 ml NS  Amiodarone infusion 1 mg/min - Use IV pump - Mix 150 mg in 100 ml NS  Lidocaine 1 mg/kg IV - q 5 minutes as 0.5 mg/kg up to 3 mg/kg total  Lidocaine Infusion 2 – 4 mg/min - Use IV pump - If successful conversion of the rhythm with lidocaine bolus  Magnesium Sulfate 1 – 2 g dilute in 10 ml of NS SLOW IV/IO Consult: Revision Date 02/28/2011 158 This Page Intentionally Left Blank ADULT ENVIRONMENTAL This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Adult Environmental ENVIRONMENTAL ASSESSMENT AE 01 Page 162 TOC Criteria and History :  Historical Findings: - Exposure to extreme temperatures - Envenomation - Wilderness exposure - Exposure to hazardous materials  Physical Findings: - Hyperthermia/Hypothermia - Altered Mental Status Shivering - Frostbite - Dyspnea - Evidence of bite, sting or exposure to chemicals - Nausea/Vomiting - Dizziness/Weakness - Sweating - Abdominal pain Assessment            C. A. B. C. Secondary Assessment Vital Signs ECG 3-Lead and 12-Lead if appropriate Blood glucose Temperature Lung sounds GCS OPQRST ASPN SAMPLE Glascow Coma Scale Eye Response Verbal Response Motor Response 4 Spontaneous 5 Orientated 6 Obeys 3 To verbal 4 Confused 5 Localizes 2 To pain 3 Inappropriate 4 Withdraws 1 No response 2 Incomprehensible 3 Flexion 1 No response 2 Extension 1 No response Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 162 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Environmental COLD RELATED EMERGENCY AE 02 Page 163 TOC Criteria and History :  Historical Findings: - Immersion or exposure to cold temperatures  Physical Findings: - Core temperature < 96 degrees F - Shivering - Altered mental status - Cyanosis Assessment:  Environmental Assessment Primary Interventions:  O2 via appropriate method  Prevent further heat loss  Passive rewarming  3-Lead ECG  12-Lead ECG Secondary Interventions:  Vascular Access Passive rewarming: Remove wet clothing Warm blankets Wrap heat packs and apply to axillary and groin regions Use warm IV fluids For persistent shivering or active seizures, refer to Seizure protocol Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 163 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Environmental Criteria and History :  Historical Findings: - Exposure to heat  Physical Findings: - Environmental potential of heat related emergency including high temperature, high humidity, and vigorous activity - Normothermic or hyperthermic with weakness, dizziness, N/V, syncope, sweating  ECG Findings: - Tachycardia Assessment:  Environmental assessment HEAT RELATED EMERGENCY AE 03 Page 164 TOC Heat Cramps - Cramps in extremities or abdomen Heat Exhaustion - Temperature normal or 1 – 2 degrees above normal with weakness, dizziness, nausea, syncope, profuse sweating, tachycardia Heat Stroke - Temperature of 105 degrees F or greater and any of the following: AMS, Sz activity, lack of sweating, cardiac arrest Primary Interventions:   O2 via most appropriate method External Cooling Revision Date 02/28/2011 Remove patient’s clothing Apply cold packs to axillary and groin regions Avoid excessive cooling 164 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Environmental HEAT RELATED EMERGENCY AE 03 Page 165 TOC Secondary Interventions:     Vascular Access Fluid Bolus Trendelenburg Ondansetron 4-8 mg IV/IO/IM  May repeat in 15 min  Ondansetron 8 mg oral disintegrating tablet (ODT) PO  Promethazine 12.5 mg IV/IO/IM for N/V - Must be diluted in 20mL NS for IV Administration - May be repeated x 1 if N/V persists after 15 minutes  If temp >102 F and any altered Mental status or any temp >105 F - Cooled Saline up to 20 ml/kg rapid IV  If hypotension persists use NonTraumatic Shock / Hypotension protocol (monitor closely for pulmonary edema) For persistent shivering or active seizures, refer to Seizure protocol Consult: Revision Date 02/28/2011 165 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Environmental INSECT / ANIMAL / SNAKE BITE AE 04 Page 166 TOC Criteria and History :  Historical Findings: - Preceding event  Physical Findings: - Pain to location of bite/sting - Known or suspected envenomation by an insect or snake Assessment:  Environmental assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:    Vascular Access Nitrous Oxide Pain Management For active seizures, refer to Seizure protocol Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 166 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Environmental NEAR DROWNING AE 05 Page 167 TOC Criteria and History :  Historical Findings: - Water submersion without cardiopulmonary arrest and without evidence of hypothermia  Physical Findings: - Dyspnea, difficulty breathing Assessment:  Environmental assessment Primary Interventions:  Remove from water  O2 via most appropriate method  Intubate - If unconscious and unable to protect airway  External warming if indicated  Vascular Access ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Secondary Interventions:    CPAP 3 – 10 cmH2O Tracheal suctioning via ETT PEEP usage during ventilation 5 – 10 cm H2O  Consider RSI PEEP: Use with caution in low perfusion state Consult: Mallampati Classification Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 167 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Environmental TOXICOLOGICAL / HAZMAT AE 06 Page 168 TOC Criteria and History :    Historical Findings: - Determine type of exposure & refer to USDOT-ERG for initial assessment and management. Physical Findings: - Findings will vary based upon contaminant. If Organophosphates (OGP’s) - SLUDGE-BM • Salivation, Lacrimation (Tearing), Urination, Diarrhea/Defecation, GI Distress, Emesis, Bradycardia, & Miosis (Pinpoint pupils) Hazardous Materials may fall under the following categories: • Chemical • Biological • Nuclear • Radioactive • Explosive Most common OGP’s are pesticides and produce an exaggerated parasympathetic response. Assessment:  Ensure that the patient has been decontaminated.  At NO TIME SHOULD EMS personnel enter the HOT or WARM Zone, unless wearing appropriate PPE.  If exposure is localized and not generalized: - Dry Chemical: Brush the chemical off and flush with copious amounts of water. - Wet Chemical: Irrigate with copious amounts of water. Primary Interventions: Medical Care should be coordinated with a Hazardous Materials Response Team Appropriate PPE may be either Level B partially encapsulated suits with PAPR (Positive Air Purifying Respirators) or Level A Fully encapsulated suits with SCBA. Water should be from a steady stream, for at least 15 – 20 minutes into a sanitary sewer   Assure scene and personal safety. Assure that patient has been decontaminated appropriately.  Provide for oxygenation and ensure patent airway  Vascular Access Secondary Interventions:   Evaluate ECG as appropriate For OGP, administer Atropine 2 mg repeated frequently until Bradycardia has resolved. Revision Date 11/01/2005 Doses in excessive of 5 – 10 mg may be required to resolve Bradycardia in OGP. 168 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Environmental TOXICOLOGICAL / HAZMAT AE 06 Page 169 TOC Consult:  RSI Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 169 This Page Intentionally Left Blank ADULT MEDICAL This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical MEDICAL ASSESSMENT AM 01 Page 173 TOC Criteria and History :   Historical Findings: - Recent events - PMHx Physical Findings: - Pain - Non-traumatic hemorrhage - Itching, swelling, hives - Altered mental status - Fever - Headache - Dyspnea Assessment:            C. A. B. C. Secondary Assessment Vital Signs (orthostatic) ECG 3-Lead and 12-Lead if appropriate Blood glucose Temperature Lung sounds GCS OPQRST ASPN SAMPLE Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 173 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical ALLERGIC REACTION AM 02 Page 174 TOC Criteria and History :   Historical Findings: - Previous history - Exposure to allergen Physical Findings: Mild Reaction – contact dermatitis (rash) and/or urticaria (hives), dermal itching Moderate Reaction – mild reaction symptoms with dyspnea Anaphylaxis – Moderate reaction symptoms with hypotension, difficulty swallowing, generalized edema, stridor Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions: Mild:  Vascular Access  Diphenhydramine 50 mg IV/IM/IO Moderate:  “Mild reaction” treatment in addition to:      Epinephrine 1:1,000 0.3 mg IM Albuterol via SVN PRN OR Levalbuterol 1.25 mg/3 ml via nebulizer - May repeat x 2 q 15 minutes Ipratroprium SVN x 1 Methylprednisolone 125 mg IV/IO Revision Date 07/26/2010 174 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical ALLERGIC REACTION AM 02 Page 175 TOC Anaphylaxis “Moderate reaction” treatment in addition to:  Epinephrine 1:10,000 0.5 – 1 mg IV/IO  Additional Epinephrine 1:10,000 0.5 – 1 mg IV/IO Epinephrine 1:1,000 0.5 mg SL - If pt is unconscious with vascular collapse Consider RSI Consult:   Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to the appropriate protocol Revision Date 07/26/2010 175 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical AMS / UNCONSCIOUS AM 03 Page 176 TOC Criteria and History :   Historical Findings: - Medical etiology Physical Findings: - Unresponsive, disoriented WITHOUT a clear mechanism for AMS Consider causes: - CVA - Hypoglycemia/hyperglycemia - Drug/ Alcohol use - Recent trauma - Hepatic disease - Acidosis/electrolyte imbalance - Sepsis - Hypotension - Hypoxemia Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:   - Do not administer Naloxone if pt is intubated Vascular Access Naloxone 0.4 mg – 2 mg IV/IO/IN for respiratory depression due to suspected narcotic overdose - Repeat PRN based on patient response  Consider RSI Consult: Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Revision Date 02/28/2011 176 Montgomery County Hospital District-EMS CEREBROVASCULAR ACCIDENT Clinical Guidelines – Adult Medical AM 04 Page 177 TOC Criteria and History :  Historical Findings: - Time of onset  Physical Findings: - AMS - B/P > 200 mmHg and/or diastolic > 110 mmHg - Unilateral weakness - Paralysis - Facial drooping - Ataxia - Aphasia/dysphasia - Headache - Visual disturbance Assessment:   Medical Assessment Neurological Exam using MCHD Prehospital Stroke Scale Primary Interventions:      O2 via most appropriate method Vascular Access For Systolic B/P > 200 mmHg and/or Diastolic B/P > 110 mmHg, reassess B/P Rapid transport to appropriate facility supine with head of stretcher at 15 degrees Contact receiving facility and report pt status  Known onset < 180 minutes, patient eligible for acute stroke intervention at appropriate facility -  Conroe Regional Medical Center Memorial Hermann – The Woodlands Houston Northwest Known onset < 9 hours, patient eligible for acute stroke intervention at appropriate facility Methodist – Main  Consider AMP Secondary Interventions:  Ondansetron 4-8 mg IV/IO/IM  Ondansetron 8 mg oral disintegrating tablet (ODT) PO Revision Date 01/26/2009 177 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical  CEREBROVASCULAR ACCIDENT AM 04 Page 178 TOC • May be repeated every 15 min Promethazine 12.5 mg IV/IO/IM - Must be diluted in 20mL NS for IV/IO Administration - May be repeated x 1 if N/V persists after 15 minutes Consult:  Labetalol 10 mg over 2 minutes IV/IO q 15 minutes if B/P remains > 160/100  Consider RSI Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 178 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical DIABETIC - HYPERGLYCEMIA AM 05 - A Page 179 TOC Criteria and History :  Historical Findings: - Known history - New onset  Physical Findings: - BGL > 180 mg/dL with one of the following: - AMS, tachypnea, abdominal pain, hypotension and tachycardia - Polyuria, Polyphagia, Polydipsia Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Fluid Bolus  Continued infusion of NS 500 ml/hr - Discontinue if pulmonary edema develops Secondary Interventions:  Obtain blood sample for lab analysis  Ondansetron 4-8 mg IV/IO/IM  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM • Must be diluted in 20mL NS For IV/IO Administration • May be repeated x 1 if N/V persists after 15 minutes Consult:  Sodium Bicarbonate 1 mEq/kg IV - If metabolic acidosis is suspected Consider when pt is tachycardic, tachypneic, altered mental status Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 1/26/2009 179 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical Revision Date 1/26/2009 DIABETIC - HYPERGLYCEMIA AM 05 - A Page 180 TOC 180 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical DIABETIC - HYPOGLYCEMIA AM 05 - B Page 181 TOC Criteria and History :   Historical Findings: - Known history - New onset Physical Findings: - BGL < 80 mg/dL - Signs and symptoms suggestive of Hypoglycemia: AMS, tremors, weakness, N/V, intense hunger, diaphoresis - BGL < 40 mg/dL should be treated, regardless of presence of other signs/symptoms Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:     Oral glucose 15-31g PO - Only in patients with intact gag reflex and able to follow commands to swallow medication Thiamine 50 mg IV/IO and 50 mg IM - Prior to D50% administration D50% 25 – 50 g IV - May be repeated x 1 q 5 if symptoms persist - Repeat BG in 10 minutes after administration of D50% Glucagon 1 mg IM/SQ if unable to obtain vascular access - Should be followed by Oral glucose once patient can follow commands and swallow Thiamine only with evidence of malnutrition Consult:  Additional D50% 25 – 50 g IV Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 6/29/2010 181 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical DYSTONIC REACTION AM 06 Page 182 TOC Criteria and History :  Historical Findings: - Recent ingestion of phenothiazines, fluphenazines, other neuroleptics or related drugs used as antipsychotics and also to treat GI disorders and nausea  Physical Findings: - Protrusion of the tongue, twisted neck or facial spasms, roving or deviated gaze, abdominal rigidity or pain, spasm of the entire body, twitching Assessment:  Promethazine Reglan (Metoclopramide) Propulsid Haldol Medical Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Diphenhydramine 50 mg IV/IM/IO Secondary Interventions: Consult:  Midazolam 2 – 5 mg IV/IM/IO if no response is seen from Diphenhydramine Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 6/29/2010 182 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical FEVER AM 07 Page 183 TOC Criteria and History :  Historical Findings: - Evidence of determinable source for sepsis  Physical Findings: - AMS - Weakness - Temperature > 101 degrees F Assessment:  - Use of full PPE is recommended Medical Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:    Fluid Bolus Acetaminophen 975 mg PO if no N/V External cooling Refer to Heat Related Emergency protocol For persistent shivering or active seizures, refer to Seizure protocol Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 6/29/2010 183 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical HYPERTENSIVE CRISIS AM 08 Page 184 TOC Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Systolic B/P >200 mmHg and/or Diastolic B/P > 110 mmHg - Evidence of end-organ dysfunction including: • Chest pain • Dyspnea • Severe headache • Nausea/Vomiting • Epistaxis Assessment:   Medical Assessment Neurological Exam using MCHD Prehospital Stroke Scale Primary Interventions:  O2 via most appropriate method  Vascular Access  For Systolic B/P >200 mmHg and/or Diastolic B/P > 110 mmHg, reassess B/P  If pt has NO clinical evidence of end organ dysfunction, transport with supportive treatment Secondary Interventions:    Ondansetron 4-8 mg IV/IO/IM Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min Promethazine 12.5 mg IV/IO/IM • Must be diluted in 20mL NS for IV/IO Administration • May be repeated x 1 if N/V persists after 15 minutes Chest pain, Abdominal Pain, Shortness of Breath, and CVA – Refer to appropriate protocol Consult: Revision Date 1/26/2009 184 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical  HYPERTENSIVE CRISIS AM 08 Page 185 TOC Labetalol 10 mg over 2 minutes IV q 15 minutes if B/P remains > 160/100 Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 1/26/2009 185 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical MALNUTRITION / DEHYDRATION AM 09 Page 186 TOC Criteria and History :  Historical Findings: - Recent illness - Poor nutrition - Anorexia - ETOH abuse  Physical Findings: - Poor skin turgor - Dizziness Assessment:  Medical Assessment Compensated Hypovolemia - Normotension and tachycardia Uncompensated Hypovolemia - Hypotension and tachycardia Contact information for APS: 1-800-252-5400 or https://www.txabusehotline.org Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:      Fluid Bolus - q 5 – 10 minutes if pt is symptomatic and there is no evidence of pulmonary edema Ondansetron 4-8mg IV/IO/IM Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min Promethazine 12.5 mg IV/IO/IM - Must be diluted in 20mL NS for IV/IO Administration - May be repeated x 1 if N/V persists after 15 minutes Thiamine 50 mg IV/IO and 50 mg IM Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 1/26/2009 186 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical NON-TRAUMATIC ABDOMINAL PAIN AM 10 Page 187 TOC Criteria and History :   Historical Findings: - Medical etiology Physical Findings: - Abdominal pain with rebound tenderness, increased pain on palpation, increased pain on movement - Symptoms of Renal calculi - Females of reproductive age who complain of abdominal pain are managed with the OB Abdominal Pain protocol - Abdominal pain secondary to trauma is managed with the Multi-system trauma protocol. Assessment:    Medical Assessment Auscultation of bowel sounds and history of bowel movement Palpate for pulsating masses Primary Interventions:  O2 via most appropriate method Secondary Interventions:  Vascular Access  Ondansetron 4-8mg IV/IO/IM  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM - May be repeated x 1 if N/V persists after 15 minutes  Pain Management Assess, document location, type, radiation, migration, response to palpation, treat, assess, retreat and reassess if necessary. Pain reduction should be offset with a good assessment and documentation pre and post drug administration. Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 187 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical NON-TRAUMATIC HEMORRHAGE AM 11 Page 188 TOC Criteria and History :   Historical Findings: - Medical etiology Physical Findings: - Hypovolemia secondary to blood loss due to medical etiology - “Coffee ground” emesis - Blood in stool - Epistaxis Consider all possible causes - Abdominal aortic aneurysm (AAA) - Ulcers/Diverticulitis/GI bleed Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:   Fluid Bolus x 2 q 5 minutes - Discontinue if pulmonary edema develops Consider Trendelenburg Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 188 Montgomery County Hospital District-EMS NON-TRAUMATIC SHOCK / HYPOTENSION Clinical Guidelines – Adult Medical AM 12 Page 189 TOC Criteria and History :   Historical Findings: - No evidence of blood loss or trauma Physical Findings: - Systolic B/P < 90mmHg - AMS - Sepsis - Tachycardia Evidence of sepsis can include any of the following:  Fever  Recent wound or surgery  Recent URI/UTI symptoms  Urinary catheter  Petechia or rash Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:   Fluid Bolus x 2 q 5 minutes - Discontinue if pulmonary edema develops Consider Trendelenburg Consult:   Dopamine Infusion 5 – 20 mcg/kg/min - Use IV pump - Administer if patient remains hypotensive 5 minutes after fluid bolus Consider RSI Dopamine Chart (gtts/min) (400mg/250 ml Normal Saline) KGS 40 50 60 70 80 90 100 MCG/ MIN 5 8 10 12 13 15 17 19 10 15 19 22 26 30 33 37 15 22 28 33 39 44 50 56 20 30 37 44 52 59 67 74 25 37 46 56 65 74 82 93 Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 189 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical OVERDOSE / POISONING AM 13 Page 190 TOC Criteria and History :  Historical Findings: - Known use of drug or alcohol use - Known or suspected ingestion or injection of pharmacoactive substance, whether intentional or accidental - Ingestion, inhalation or absorption of potentially harmful non-pharmaceutical substance  Physical Findings: - Lethargy, AMS, combative, unresponsive Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method 100% O2 for Carbon monoxide Consider Hyperbaric Therapy Secondary Interventions:      Tricyclic Antidepressants include: Vascular Access - Elavil Naloxone 0.4 mg – 2 mg IV/IO/IN for - Amitriptyline respiratory depression due to - Imipramine suspected narcotic overdose - Doxepin - Repeat PRN based on patient - Nortriptyline response Sodium Bicarbonate 0.5 – 1 mEq/kg IV/IO Calcium Channel Blockers include: - For Tricyclic anti-depressant - Amlodipine (TCA) overdose with AMS and - Diltiazem tachycardia and/or widened - Nifedipine QRS complexes - Verapamil - For ethylene glycol ingestion (antifreeze, detergents, paints) Atropine 2 mg IV/IM/IO - For OGP poisoning with parasympathetic symptoms - Repeat q 5 min as needed Charcoal 50 – 100 grams PO within 1 hour of ingestion Revision Date 02/28/2011 190 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical     Calcium Gluconate 4.65 mEq IV/IO - For calcium channel blocker overdose Glucagon 1 mg IV/IM/SQ/IO - Beta blocker or calcium channel blocker overdose Consider contacting Poison control (1-800-POISON-1 or 1-800-764-7661) Hydroxocobalamin 5g (Cyanokit) - For known/suspected Cyanide exposure OVERDOSE / POISONING AM 13 Page 191 TOC Beta Blockers include: - Atenolol - Metoprolol - Propranolol - Corgard - Inderal - Lopressor - Tenormin - Trandate Consult:    Midazolam 2 – 5 mg IV - For cocaine or methamphetamine overdose Diazepam 5 – 10 mg IV - For cocaine or methamphetamine overdose RSI Revision Date 02/28/2011 191 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical SEIZURES AM 14 Page 192 TOC Criteria and History :  Historical Findings: - History of seizures - Head trauma - New onset  Physical Findings: - Post-ictal Witnessed, reported or suspected seizure prior to EMS arrival - Active Actively seizing patient upon EMS arrival Assessment: Consider possible causes:  Medical Assessment - Head trauma - Febrile - Epilepsy - Overdose - Withdrawals - Hypoglycemia - Unknown etiology Primary Interventions:  O2 via most appropriate method  Vascular Access  External cooling, if febrile Secondary Interventions: Active  Midazolam 2 – 5 mg IV/IM/IO/IN - Repeat x 1, Midazolam 2 – 5 mg IV/IM/IO q 5 min  Diazepam 2 – 10 mg IV/IO  Diazepam 4 – 20 mg PR - If unable to establish IV Consult:  Additional Midazolam 2 – 5 mg IV/IM/IO  Additional Diazepam 2 – 10 mg IV/IO  Additional Diazepam 4 – 20 mg PR if unable to establish IV Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 192 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Medical SYNCOPE AM 15 Page 193 TOC Criteria and History :    Historical Findings: - History of loss of consciousness Physical Findings: - Common “faint” (vasovagal syncope) - Postural “faint” (orthostatic syncope) - Hyperventilation syncope ECG Findings: - No evidence of cardiac ischemia Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method  Once you have completed a patient assessment, and a cause of syncope has been determined, refer to the appropriate protocol. Syncope is arrthymia related until proven otherwise. Maintain high index of of suspicion. Secondary Interventions:  Vascular Access Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 193 This Page Intentionally Left Blank ADULT RESPIRATORY This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory Criteria and History :  Historical Findings: - Use of inhaled medications, steroids, diruretics, antihypertensive medications - Smoking - Fever - Productive cough - Recent surgery  Physical Findings: - Dyspnea, tachypnea - Cyanosis - Clubbing - Edema (Pulmonary, pedal, ascites, presacral) - Wheezing, rales, rhonchi, absent/decreased breath sounds, stridor - Chest pain - Bronchoconstriction - Jugular venous distention (JVD) RESPIRATORY ASSESSMENT AR 01 Page 197 TOC Consider all possible causes and refer to appropriate protocol: - Pulmonary Embolism - Anxiety - COPD - Asthma - Airway obstruction - Pneumonia - CHF - Pneumothorax - Allergic reaction - Aspiration Assessment:              C. A. B. C. Secondary Assessment Vital Signs (orthostatic) ECG 3-Lead and 12-Lead if appropriate Blood glucose Temperature Lung sounds GCS OPQRST ASPN SAMPLE Capnography Mallampati score Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 197 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory Revision Date 11/01/2005 RESPIRATORY ASSESSMENT AR 01 Page 198 TOC 198 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory AIRWAY OBSTRUCTION AR 02 Page 199 TOC Criteria and History :  Historical Findings: - Recent event  Physical Findings: - Partial or complete airway obstruction - Secondary to foreign body aspiration - Decreased LOC - Cyanosis - Obvious inadequate air exchange Assessment:  Respiratory assessment Primary Interventions:  Abdominal/chest thrusts - If patient is conscious  Direct laryngoscopy and removal of foreign object with Magill forceps or suction - If patient is unconscious and there is a complete obstruction  O2 via most appropriate method Secondary Interventions:  Vascular Access  Consider surgical airway if obstruction is not relieved by other means Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 199 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory BRONCHOSPASM AR 03 Page 200 TOC Criteria and History :  Historical Findings: - History of asthma  Physical Findings: - Dyspnea with wheezing or prolonged expiratory phase Assessment:  Respiratory assessment Primary Interventions:    O2 via most appropriate method Vascular Access Fluid Bolus Secondary Interventions:      Albuterol via SVN PRN OR Levalbuterol 1.25 mg / 3ml via nebulizer - May repeat x 2 q 15 minutes Ipratroprium SVN x 1 CPAP 3 – 8 cmH2O Methylprednisolone 125 mg IV/IO OR Decadron 10 mg IV/IO CPAP settings should begin at 3, not to exceed 8 cmH2O for Bronchospasm Consult:    Epinephrine 1:1,000 0.3 mg IM Consider RSI ο Post intubation use Ketamine 2 – 4 mg/kg IM or 1 – 2 mg/kg IV ο May Repeat q 10 minutes if sedation inadequate Magnesium Sulfate 1 g IV/IO infusion - May be repeated x 1 Revision Date 02/28/2011 Magnesium Sulfate Infusion Mix 1 g in 100 ml NS and infuse over 10 minutes using pump Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as 200 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory BRONCHOSPASM AR 03 Page 201 TOC possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Revision Date 02/28/2011 201 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory CHRONIC OBSTRUCTED PULMONARY DISEASE AR 04 Page 202 TOC Criteria and History :  Historical Findings: - History of COPD - Chronic bronchitis or emphysema  Physical Findings: Abnormal breath sounds Assessment: COPD - Chronic Obstructed Pulmonary Disease  Respiratory assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Fluid Bolus Secondary Interventions:   Albuterol via SVN PRN Levalbuterol 1.25 mg / 3 ml via nebulizer - May repeat x 2 q 15 minutes  Ipratroprium SVN x 1  CPAP 3 – 10 cmH2O  Methylprednisolone 125 mg IV/IO OR Decadron 10 mg IV/IO Consult:  Consider RSI Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 202 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory Revision Date 08/01/2007 CHRONIC OBSTRUCTED PULMONARY DISEASE AR 04 Page 203 TOC 203 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory HYPERVENTILATION AR 05 Page 204 TOC Criteria and History :  Historical Findings: - Stress or anxiety  Physical Findings: - Increased rate/depth of respiration without evidence of hypoxemia - Facial/peripheral tingling - Extremity cramping or carpopedal spasm - Dizziness  ECG Findings: - Tachycardia Assessment:  Respiratory assessment Primary Interventions:   O2 via most appropriate method Psychological support Secondary Interventions:  Vascular Access  Midazolam 2 – 5 mg IV/IM/IO - For extreme anxiety Consult: If unable to control hyperventilation within 10 minutes, consult for sedation and see adult behavioral protocol Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 204 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory PNEUMONIA AR 06 Page 205 TOC Criteria and History :  Historical Findings: - Recent upper respiratory illness  Physical Findings: - Fever - Productive cough - Wheezing, rhonchi or rales Assessment:  Respiratory assessment Primary Interventions:  O2 Via most appropriate method  Vascular Access  Albuterol via SVN PRN  Levalbuterol 1.25 mg / 3 ml via nebulizer - May repeat x 2 q 15 minutes Secondary Interventions:     CPAP 3 – 10 mmHg Fluid Bolus Acetaminophen 975 mg PO Ipratropium SVN x 1 Consult:  Consider RSI Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 205 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory PULMONARY EMBOLISM AR 07 Page 206 TOC Criteria and History :  Historical Findings: - Recent surgery - Thrombosis/Embolism - Recent travel  Physical Findings: - Dyspnea, sudden onset - Leg pain / swelling - Chest pain - Hemoptysis - JVD  ECG Findings: - A-fib - Tachycardia Assessment:  Respiratory assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Fluid Bolus if B/P < 90 mmHg  Rapid transport Secondary Interventions:   Intubate - If patient is in severe distress or unable to protect airway Place patient in left lateral recumbent position Revision Date 06/26/2006 ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg 206 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory PULMONARY EMBOLISM AR 07 Page 207 TOC Consult:   Consider RSI Dopamine Infusion 5 – 20 mcg/kg/min - Use IV pump - Administer if patient remains hypotensive 5 minutes after fluid bolus Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible Dopamine Chart (gtts/min) (400mg/250 ml Normal Saline) KGS 40 50 60 70 80 90 100 MCG/ MIN 5 8 10 12 13 15 17 19 10 15 19 22 26 30 33 37 15 22 28 33 39 44 50 56 20 30 37 44 52 59 67 74 25 37 46 56 65 74 82 93 Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 06/26/2006 207 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Respiratory RESPIRATORY DISTRESS AR 08 Page 208 TOC Criteria and History :   Historical Findings: - Significant respiratory history - New onset Physical Findings: - Dyspnea without a clear etiology - Abnormal breath sounds Assessment:  Respiratory assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:    Vascular Access Albuterol via SVN x 1 Levalbuterol 1.25 mg/ 3ml via nebulizer If no beneficial response seen with Xopenex, consider other causes and treatment. Consult:      Albuterol via SVN PRN OR Levalbuterol 1.25 mg / 3 ml via nebulizer Ipratroprium SVN x 1 Consider RSI Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 208 OBSTETRICAL This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical OB ASSESSMENT OB 01 Page 211 TOC Criteria and History :   Historical Findings: - Pregnancy, spontaneous abortion Physical Findings: - Abdominal pain - Abnormal vaginal hemorrhage Assessment:     C. A. B. C. Secondary Assessment Vital Signs ECG 3-Lead and 12-Lead if appropriate  Blood glucose  Temperature  Lung sounds  GCS  OPQRST  ASPN  SAMPLE  Physical exam including palpation of all abdominal regions  Determination of para and gravida and estimated date of confinement  Check for Vaginal discharge / hemorrhage / crowning/ limbs Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 211 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical ABDOMINAL PAIN - FEMALE OB 02 Page 212 TOC Criteria and History :   Historical Findings: - Medical etiology Physical Findings: - Any female of child-bearing age complaining of abdominal pain without evidence of labor or trauma. Assessment:  OB Assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:  Vascular Access  Ondansetron 4-8 mg IV/IO/IM OR  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM - May be repeated x 1 if N/V persists after 15 minutes  Pain Management Assess, document location, type, radiation, migration, response to palpation, treat, assess, retreat and reassess if necessary. Pain reduction should be offset with a good assessment and documentation pre and post drug administration. Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 212 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical PRE-ECLAMPSIA / TOXEMIA OB 03 Page 213 TOC Criteria and History :   Historical Findings: - Gravid female with intra-uterine pregnancy with greater than 20 weeks gestation Physical Findings: - Persistent hypertension of systolic of 140 and/or diastolic of 90 or greater - One or more of:  Peripheral edema  Nausea/vomiting  Headache Assessment:  OB Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Place patient in left lateral recumbent position Outside sensory stimulation should be MINIMAL Secondary Interventions:  Ondansetron 4-8 mg IV/IO/IM/IN  OR  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM - May be repeated x 1 if N/V persists after 15 minutes Consult:   Magnesium sulfate 2 g infusion - May be repeated x 1 Labetelol 10 mg SLOW IV/IO - If hypertension persists refractory to Magnesium sulfate Revision Date 02/28/2011 Magnesium sulfate Mix 2 g in 100 ml NS and infuse over 10 minutes using pump 213 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical ECLAMPSIA / TOXEMIA OB 04 Page 214 TOC Criteria and History :   Historical Findings: - Gravid female with intra-uterine pregnancy with greater than 20 weeks gestation or post partum with signs and symptoms of toxemia Physical Findings: - Active seizures - Persistent hypertension of systolic of 140 and/or diastolic of 90 or greater - One or more of:  Peripheral edema  Nausea/vomiting  Headache Assessment:  OB Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Midazolam 2 – 5 mg IV/IO/IM/IN  Place patient in left lateral recumbent position Secondary Interventions:  Magnesium Sulfate 2 g IV infusion - May be repeated x 1  Ondansetron 4-8 mg IV/IO/IM/IN  OR  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM - May be repeated x 1 if N/V persists after 15 minutes Magnesium sulfate Mix 2 g in 100 ml NS and infuse over 10 minutes using pump Consult:  Labetelol 10 mg SLOW IV/IO - If hypertension or seizures persist refractory to Magnesium Revision Date 03/02/2011 214 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical ECLAMPSIA / TOXEMIA OB 04 Page 215 TOC sulfate Revision Date 03/02/2011 215 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical LABOR OB 05 Page 216 TOC Criteria and History :   Historical Findings: - Gravid female with intrauterine pregnancy > 20 weeks Physical Findings: - Back and/or abdominal pain which occurs periodically, at regular intervals - “Bag of waters” intact or ruptured Assessment:  OB Assessment Primary Interventions:  O2 via most appropriate method  Place patient in left lateral recumbent position Secondary Interventions:  Vascular Access  Ondansetron 4-8 mg IV/IO/IM/IN  OR  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM - May be repeated x 1 if N/V persists after 15 minutes Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 216 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical CHILDBIRTH / IMMINENT DELIVERY OB 06 Page 217 TOC Criteria and History :   Historical Findings: - Gravid female with intrauterine pregnancy > 20 weeks Physical Findings: - Presentation of a viable fetus through cervix Assessment:  OB Assessment Primary Interventions:     O2 via most appropriate method Control delivery Deliver neonate Refer to post-delivery care of neonate protocol  Fundus massage post delivery hemorrhage Secondary Interventions:  Vascular Access Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 217 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical NEONATE CARE OB 07 Page 218 TOC Criteria and History :   Historical Findings: - Neonate less than 12 hours old Physical Findings: - Viable baby Assessment:     C.A.B.C. APGAR Vital signs Blood glucose; if < 40, refer to pediatric hypoglycemia protocol  ECG Primary Interventions:  Dry, Warm, Position, Suction and Stimulate  O2 via most appropriate method  Chest compressions if heart rate < 60 Secondary Interventions:   Vascular Access Naloxone 0.1 mg/kg IV/IO/IN - Max single dose of 2 mg - Repeat every 2 – 3 minutes  Epinephrine 0.01 mg/kg (0.1 ml/kg 1:10,000) IV/IO - q 3 – 5 min  IF NO VASCULAR ACCESS, Epinephrine 0.1 mg/kg (0.1 ml/kg 1:1,000) ET - q 3 – 5 min - BVM assist if apneic OR heart rate < 100 - Do not administer Naloxone if patient is intubated. Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol  Nor Neonate transfer refer to CG 39 “Allied Health Care Providers” Revision Date 06/21/2012 218 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical LIMB PRESENTATION OB 08 Page 219 TOC Criteria and History :   Historical Findings: - Gravid female with intrauterine pregnancy > 20 weeks Physical Findings: - Limb presentation at vaginal opening Assessment:  OB Assessment Primary Interventions:    RAPID TRANSPORT O2 via most appropriate method Place patient in left lateral recumbent position Secondary Interventions:  Vascular Access  Ondansetron 4-8 mg IV/IO/IM/IN  OR  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM - May be repeated x 1 if N/V persists after 15 minutes Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 219 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical PROLASPED UMBILICAL CORD OB 09 Page 220 TOC Criteria and History :   Historical Findings: - Gravid female with intrauterine pregnancy > 20 weeks Physical Findings: - Presentation of umbilical cord through vaginal opening Assessment:  OB Assessment Primary Interventions:     RAPID TRANSPORT O2 via most appropriate method Wrap umbilical cord in moist sterile dressing Insert gloved hand into vagina and move neonate’s head so it does not compress umbilical cord Secondary Interventions:   Place mother prone, in knee – to – chest position Vascular Access Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date11/01/2005 220 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical SPONTANEOUS ABORTION OB 10 Page 221 TOC Criteria and History :   Historical Findings: - Known or suspected intrauterine pregnancy Physical Findings: - Vaginal hemorrhage that is non-menstrual - Abdominal or back cramping or pain - Tissue passing with blood Assessment:  OB Assessment Primary Interventions:   O2 via most appropriate method Control hemorrhage Secondary Interventions:  Vascular Access  Collect all passed tissue, if possible Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date11/01/2005 221 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Obstetrical VAGINAL BLEEDING OB 11 Page 222 TOC Criteria and History :   Historical Findings: - Gravid female with intrauterine pregnancy > 20 weeks - Non-pregnancy related Physical Findings: - Vaginal hemorrhage that is non-menstrual without: - Labor - History of trauma - or evidence of spontaneous abortion Assessment:  OB Assessment Primary Interventions:  Place patient in left lateral recumbent position  O2 via most appropriate method  Rapid transport Secondary Interventions:   Vascular Access Fluid Bolus, titrate to systolic pressure of 90 mmHg Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date11/01/2005 222 This Page Intentionally Left Blank Revision Date11/01/2005 223 ADULT TRAUMA This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma TRAUMA ASSESSMENT AT 01 Page 226 TOC Criteria and History :  Historical Findings: - History of recent trauma - MOI indicative of trauma  Physical Findings: - Evidence of trauma Assessment:             C. A. B. C. Secondary Assessment Vital Signs ECG 3-Lead and 12-Lead if appropriate Blood glucose Temperature Lung sounds GCS OPQRST ASPN SAMPLE Trauma Score Glascow Coma Scale Eye Response Verbal Response Motor Response 4 Spontaneous 5 Orientated 6 Obeys 3 To verbal 4 Confused 5 Localizes 2 To pain 3 Inappropriate 4 Withdraws 1 No response 2 Incomprehensible 3 Flexion 1 No response 2 Extension 1 No response Critical Points:  Any changes in patient condition, refer to appropriate protocol  Refer to destination criteria guidelines for appropriate facility. Revision Date 11/01/2005 226 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma AMPUTATION AT 02 Page 227 TOC Criteria and History :  Historical Findings: - Mechanism of injury  Physical Findings: - A severed part that is completely separated from the body Assessment:  Trauma assessment Primary Interventions:     O2 via most appropriate method Control hemorrhage Vascular Access Fluid Bolus if severe blood loss has occurred To care for amputated part - Rinse with sterile water Place in a bag Keep cool but do not place directly on ice Secondary Interventions:  Splint any associated fracture or dislocation  Ondansetron 4-8 mg IV/IO/IM/IN  OR  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM - May repeat x 1 if N/V persists after 15 minutes  Nitrous Oxide  Pain Management Consider pressure points or tourniquet if hemorrhage cannot be controlled by direct pressure Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 227 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma BURNS AT 03 Page 228 TOC Criteria and History :   Historical Findings: - Mechanism of injury Physical Findings: Tissue injury from direct contact with: - Heat source - Chemical reaction - Inhalation - Electrical / lightning contact Inhalation Injuries/Burns with any one of the following: - Singed nasal hairs or oral mucosa - Erythema of the palate, soot in the mouth, larynx or sputum - Rapid, shallow ventilation with tachypnea > 40 AND decreased mental status - Respiratory rate < 8 - Mechanical airway obstruction from trauma, edema, or laryngospasm - Signs of respiratory distress such as nasal flaring, respiratory crowing or stridor, anxiety, agitation, or combativeness - Edema associated with a burn of the face or neck - Unconsciousness Assessment: Rule of Nines: refer to appendix  Trauma assessment Primary Interventions:    Remove the burn source O2 via most appropriate method Vascular Access - Revision Date 01/262/009 Remove jewelry and resticting clothing Brush off any powdered chemical Irrigate chemical burn site with water, if appropriate to chemical V (fluids volume)= TBSA of burn (%) x weight (kg) x 4 228 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma Secondary Interventions:  Treat Underlying Injuries  Dress burns as follows - TBSA < 15% use burn gel - TBSA > 15% use dry sterile dressing or burn sheet  Pain Management  Ondansetron 4-8 mg IV/IO/IM/IN  OR  Ondansetron 8 mg oral disintegrating tablet (ODT) PO • May be repeated every 15 min  Promethazine 12.5 mg IV/IO/IM - May repeat x 1 if N/V persists after 15 minutes - - BURNS AT 03 Page 229 TOC Do not administer MS to patients with severe respiratory burns unless airway is secured Initial dose of MS for severe burns should be 3 – 5 mg IV Keep the patient warm after removing burn source and possibly contaminated clothing Consult:  RSI for respiratory burns Mallampati Classification Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible Critical Points:  Any changes in patient condition, refer to appropriate protocol  Appropriate Destination : UTMB or Hermann Hospital - For inhalation / hands; - >30% TBSA 2nd degree and/or higher; or <12 and > 65 years of age Revision Date 01/262/009 229 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma TASER AT 04 Page 230 TOC Criteria and History :  Historical Findings: - Patient shot with a taser gun  Physical Findings: - Taser probe imbedded in a patient Assessment:  Trauma assessment Primary Interventions:   Assure scene and personal safety. Assure electrical output is no longer surging through the probe  Remove probe from patient unless embedded in breast area, groin, or face Secondary Interventions:  To remove probe, hold skin taut, grasp probe between thumb and forefinger, and pull straight out. Wound care Consult: Critical Points:  Any changes in patient condition refer to appropriate protocol Revision Date 11/01/2005 230 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma EVISCERATION AT 05 Page 231 TOC Criteria and History :  Historical Findings: - Mechanism of injury  Physical Findings: - Protrusion of internal organs through a wound Assessment:  Trauma assessment Primary Interventions:    Spinal motion restriction if indicated O2 via most appropriate method Occlude wound with a sterile, moist dressing and bandage Secondary Interventions:   Vascular Access Pain Management Consult: Critical Points:  Any changes in patient condition refer to appropriate protocol Revision Date 08/01/2007 231 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma EYE INJURY AT 06 Page 232 TOC Criteria and History :  Historical Findings: - Decreased or loss of vision - Mechanism of injury - Sprayed with CS spray  Physical Findings: - Injury to the globe, open or closed, including:  Corneal abrasion  Foreign body in eye  Chemical bum  Lacerated or avulsed globe  "Arc" burn of globe - Excessive tearing and burning of the eyes, nasal drainage, salivation Assessment:  Trauma assessment Primary Interventions:   Spinal motion restriction if indicated Dress and bandage wound as appropriate Secondary Interventions:  IF chemical bum/ CS or OC Spray: - Flush continuously with copious amounts of water or NS  IF open injury to globe: - Shield both eyes  IF corneal abrasion, arc bum, or foreign body: - Tetracaine 1 – 2 gtt in affected eye Repeat as needed - Remove foreign body if globe not penetrated - Shield affected eye  Vascular Access - If severe pain or nausea and/or vomiting present and able to accomplish without increasing Intraocular pressure  Nitrous Oxide (Self-administered)  Pain Management Consult: Critical Points: Revision Date 08/01/2007 232 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma HEAD TRAUMA AT 07 Page 233 TOC Criteria and History :  Historical Findings: - Recent event - Mechanism of injury  Physical Findings: - Altered mental status - Loss of consciousness Assessment:  Glascow Coma Scale Trauma assessment Eye Response Verbal Response Motor Response 4 Spontaneous 5 Orientated 6 Obeys 3 To verbal 4 Confused 5 Localizes 2 To pain 3 Inappropriate 4 Withdraws 1 No response 2 Incomprehensible 3 Flexion 1 No response 2 Extension 1 No response Primary Interventions:  Helmet Removal - For airway management if clinically indicated  Spinal Motion Restriction  O2 via most appropriate method  Inline intubation, if needed Secondary Interventions:  Vascular Access Revision Date 11/01/2005 Elevate head to 30 degree angle Inline Intubation - Limit 2 attempts then use Combitube Helmet Removal Maintain neutral alignment with padding as needed after removal If patient is hypotensive, look for and treat other injuries as well 233 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma Consult:   RSI Midazolam 2 – 5 mg IV/IM/IO for patient safety sedation in combative patient HEAD TRAUMA AT 07 Page 234 TOC Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Rapid transport to appropriate facility is crucial  Any change in patient condition refer to appropriate protocol Revision Date 11/01/2005 234 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma MULTI-SYSTEM TRAUMA AT 08 Page 235 TOC Criteria and History :  Historical Findings: - Mechanism of injury  Physical Findings: - Injury to the chest, abdomen or pelvis - Multiple soft-tissue or musculoskeletal injuries Assessment:  Trauma assessment Primary Interventions:     Spinal Motion Restriction O2 via most appropriate method Inline intubation, if needed Occlude open chest wounds Inline Intubation - limit 2 attempts then use Combitube Secondary Interventions:     Chest Decompression as needed Vascular Access - Bilateral, using large bore catheters - Consider Blood-Y Fluid Bolus to systolic B/P of 90 mmHg Fentanyl only from Pain Management Consult:   RSI Pericardiocentesis Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any change in patient condition refer to appropriate protocol Revision Date 11/01/2005 235 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma MUSCULOSKELETAL-SOFT TISSUE INJURY AT 09 Page 236 TOC Criteria and History :   Historical Findings: - Mechanism of injury Physical Findings: - Pain on palpation or movement - Ecchymosis, swelling, deformity If patient is found to have lain motionless in one position for a period equal to or greater than 6 hours as a result of a fall or otherwise, be cautious for development of compartmental syndrome. Patients meeting this criteria should have gentle handling and be transported for evaluation. Assessment:  Trauma assessment Primary Interventions:  O2 via most appropriate method  Spinal motion restriction  Control hemorrhage  Splint Check PMS before and after applying splint Secondary Interventions:      Vascular Access Cooling of injury site Nitrous Oxide (self administered) Pain Management Fracture reduction by inline traction if no pulse is detected and if is a closed fracture - If still no pulse, splint in position Consult: Critical Points:  Any change in patient condition refer to appropriate protocol Revision Date 08/01/2007 236 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma PENETRATING INJURY AT 10 Page 237 TOC Criteria and History :  Historical Findings: - Mechanism of injury - Note ballistics  Physical Findings: - A penetrating injury to any body part - Entrance/ exit wounds Assessment:  Trauma assessment Primary Interventions:  O2 via most appropriate method  Occlude chest wounds  Control hemorrhage  Vascular Access  Spinal Motion Restriction  Chest decompression as needed Secondary Interventions:    Stabilize impaled objects Bandage and dress open wounds Pain Management Consult: Critical Points:  Any change in patient condition refer to appropriate protocol Revision Date 08/01/2007 237 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma SEXUAL ASSAULT AT 11 Page 238 TOC Criteria and History :  Historical Findings: - Report of recent sexual assault  Physical Findings: - Signs of assault or injury Assessment:  Trauma assessment Primary Interventions:    Assure scene and personal safety Provide emotional support O2 via most appropriate method Do not let patient bathe or change clothing. Collect any pertinent items in an unused biohazard bag, and transport with the patient. Any blankets or sheets used by or on patient during transport should accompany patient into the receiving facility. In the event of hostile family or caregivers, avoid confrontations that might interfere with removing patient from the environment. Secondary Interventions:  Treat underlying injuries Consult: Critical Points:  Any changes in patient condition refer to appropriate protocol  Appropriate destination: Memorial Hermann – The Woodlands  Refer to appropriate protocol for specific injuries or conditions. Revision Date 08/01/2007 238 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma SPINAL TRAUMA AT 12 Page 239 TOC Criteria and History :  Historical Findings: - Mechanism of injury  Physical Findings: - Presence of decreased neurological function below site of injury - Loss of sensation - Inability to move - Hypotension Assessment:  Trauma assessment Primary Interventions:   Spinal Motion Restriction O2 via most appropriate method Secondary Interventions: • • • • • • Vascular Access Fluid Bolus to systolic B/P of 90 mmHg Ondansetron 4-8 mg IV/IO/IM/IN OR Ondansetron 8 mg oral disintegrating tablet (ODT) PO ο May be repeated x 1 Promethazine 12.5 mg IV/IO/IM ο May repeat x 1 if N/V persists after 15 minutes Consult:  RSI Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points: Revision Date 01/26/2009 239 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma   SPINAL TRAUMA AT 12 Page 240 TOC Any change in patient condition refer to appropriate protocol Transport to appropriate facility Revision Date 01/26/2009 240 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma TRAUMATIC ARREST AT 13 Page 241 TOC Criteria and History : • Historical Findings: - Recent traumatic event - Surgical problems • Physical Findings: - Trauma - Apneic - Pulseless • ECG Findings: - Any non-perfusing rhythm, though not established until after initial care Assessment : • Trauma Assessment: - If injuries are obviously incompatible with life –  DO NOT ATTEMPT RESUSCITATION  Provide survivor/responder grief support & assist law enforcement as needed Primary Interventions : If Thoracoabdominal is Present or Suspected:      Immediate bilateral chest decompressions Evaluate for ROSC If no ROSC, then immediate Pericardiocentesis Reevaluate for ROSC. If no ROSC then: BLUNT MECHANISM Evaluate rhythm  If asystole, immediately discontinue resuscitation efforts  If PEA or v-fib/v-tach, consider treating with appropriate medical SDO  If medical resuscitation is elected, treat cardiac arrest per medical SDO(s), and care for injuries per appropriate trauma SDO(s) Revision Date 06/21/2012 Goal: Accomplish in first 2 minutes at patient side PENETRATING MECHANISM If transport time to Level I/III Center is: LESS Than or Equal to 19 mins:  Spinal Motion Limitation as appropriate  Immediately initiate transport to nearest designated trauma center and continue with Traumatic Arrest SDO If transport time to Level I/III Center is: GREATER than 19 mins:  Verify and document the absence of a pulse and heart sounds  Discontinue resuscitation 241 Montgomery County Hospital District-EMS Clinical Guidelines – Adult Trauma TRAUMATIC ARREST AT 13 Page 242 TOC If No Thoracoabdominal Involvement OR if Thoracoabdominal Trauma Management is Completed: • • • • CPR Control exsanguinating external bleeding, using tourniquets as appropriate Maintain open airway and provide BVM ventilation with 100% Oxygen Assess ECG - If Asystole, without chest involvement (example: isolated traumatic amputation)  DO NOT ATTEMPT RESUSCITATION  Provide grief support and LEO assistance as needed - If PEA or V-fib/V-Tach  Isolated extremity trauma: rhythm-specific care and transport to nearest hospital  Thoracoabdominal: rhythm-specific care and continue transport to nearest designated trauma center Secondary Interventions : Should not delay transport • Bilateral large bore IV or IO catheters with consideration to blood “Y” tubing • Fluid Bolus to a systolic B/P of 90mmHg if ROSC accomplished • ETT or Blind Insertion Airway Device placement with positive pressure ventilations if BVM only is not effective in ventilating • #18fr Nasogastric tube placement • Dysrhythmia treatment per specific protocol Special Considerations : • • • • • • • • If ROSC occurs at any point, transport to nearest designated trauma center Assure safety of all responders before intervention In multi-patient events, traumatic arrests do not receive intervention until there are sufficient responders present to meet the needs of living patients Chest decompression and/or pericardiocentesis should not be delayed for any other medical procedure to be accomplished, including CPR. When multiple providers are on scene, other primary interventions, such CPR, can occur simultaneously, so long as they do not delay chest decompression and/or pericardiocentesis Consider binding the pelvis if blunt mechanism Consider early reduction of long bone fractures Consider potential medical causes of traumatic events Injuries obviously incompatible with life include: - massive deformity of head or chest - decapitation - incineration - situation-specific evidence of futility in resuscitation. If in doubt, place the patient on the cardiac monitor Revision Date 06/21/2012 242 PEDIATRIC BEHAVIORAL This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Behavioral BEHAVIORAL ASSESSMENT PB 01 Page 245 TOC Criteria and History :  Historical Findings: - PMHX of psychiatric problems - Use of psychiatric medications - Substance abuse  Physical Findings: - Altered Mental Status - Evidence of trauma - Fear, anger, confusion, or hostility Assessment:  Determine that the scene is safe before entering  GCS  C.A.B.C.  Secondary Assessment  Vital signs  Blood glucose  Pertinent PMHx - Does the patient have previous suicide attempts or ideations? - Is the patient under care of a psychologist / psychiatrist? - Is the patient cared for by others or self-reliant?  SUBECT IN CUSTODY RISK ASSESSMENT SCALE (SICRAS) Glascow Coma Scale Eye Response Verbal Response Motor Response 4 Spontaneous 5 Orientated 6 Obeys 3 To verbal 4 Confused 5 Localizes 2 To pain 3 Inappropriate 4 Withdraws 1 No response 2 Incomprehensible 3 Flexion 1 No response 2 Extension 1 No response Critical Points:  Any changes in patient condition refer to appropriate protocol Revision Date 11/01/2005 245 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Behavioral ABUSE / NEGLECT PB 02 Page 246 TOC Criteria and History :   Historical Findings: - Recent events Physical Findings: - Contusions at different healing stages - Malnourished appearance - Withdrawn Assessment:  Behavioral Assessment Primary Interventions:    Apply pressure to any hemorrhage O2 via most appropriate method Spinal Motion Restriction, if indicated Secondary Interventions:    Bandaging / splinting Vascular Access Report abuse to appropriate agencies  C-spine clearance, if indicated Contact information for CPS: 1-800-252-5400 or https://www.txabusehotline.org Consult: Critical Points:  Any changes in patient condition refer to appropriate protocol Revision Date 11/01/2005 246 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Behavioral AGGRESSIVE / VIOLENT BEHAVIOR PB 03 Page 247 TOC Criteria and History :  Historical Findings: - Known violence - Aggression  - Physical Findings: Agitation Offensive posture Combative Hallucinations Assessment:  Behavioral Assessment Primary Interventions:     Reassure patient If patient is physically harmful, soft restraints O2 via most appropriate method Spinal Motion Restriction, if indicated Secondary Interventions:  Vascular Access    Midazolam 0.1 mg/kg IV/IM/IO Diazepam 0.2 – 0.3 mg/kg IV/IO C-spine clearance, if indicated Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 247 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Behavioral ANXIETY / EMOTIONAL DISTRESS PB 04 Page 248 TOC Criteria and History :   Historical Findings: - History of Recent Traumatic Event - Post Trauma Stress Disorder Physical Findings: - Agitation - Hyperventilation - Hallucinations Assessment:  Behavioral Assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:  Vascular Access    Midazolam 0.1 mg/kg IV/IM/IO Diazepam 0.2 – 0.3 mg/kg IV/IO C-spine clearance, if indicated Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 248 PEDIATRIC CARDIAC This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac Criteria and History:  Historical Findings: - Preceding Symptoms - CPR and/or Treatment PTA - PMHx  Physical Findings: - Altered mental status - Slow, fast or absent pulse - Irregular pulse - Dyspnea/Apnea - Chest pain/Palpitations - Diaphoresis - Pale, ashen or mottled skin Assessment:  C. A. B. C.  Secondary Assessment  Vital Signs  ECG 3-Lead and 12-Lead - Right sided 12-Lead if indicated  Blood glucose  Lung sounds  GCS  OPQRST  ASPN  SAMPLE Revision Date 11/01/2005 CARDIAC ASSESSMENT PC 01 Page 251 TOC Glascow Coma Scale Eye Response Verbal Response Motor Response 4 Spontaneous 5 Orientated 6 Obeys 3 To verbal 4 Confused 5 Localizes 2 To pain 3 Inappropriate 4 Withdraws 1 No response 2 Incomprehensible 3 Flexion 1 No response 2 Extension 1 No response 251 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac ASYSTOLE PC 02 Page 252 TOC Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Unconscious - Pulseless - Agonal respirations; apnea  ECG Findings: - Asystole confirmed in two or more leads Assessment:  ∼ Determine if resuscitation is medically inappropriate Normothermic rigor-mortis Injuries Incompatible with life Decomposition Pulseless, apneic patients in multiple casualty situations Proper DNR documentation Cardiac Assessment Primary Interventions:      CPR - BVM with high-flow O2 - ResQPOD - Maintain open airway with OPA Intubate Vascular Access Epinephrine 0.01 mg/kg (0.1 ml/kg 1:10,000) IV/IO - q 3 – 5 min IF NO VASCULAR ACCESS, Epinephrine 0.1 mg/kg (0.1 ml/kg 1:1,000) ET - q 3 – 5 min ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Remove ResQPOD if ROSC occurs immediately Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg ∼ Look for causes for asystolic rhythm Secondary Interventions:  Fluid Bolus - May repeat x 2 Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/08/2006 252 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac BRADYCARDIA PC 03 Page 253 TOC Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Weak, dizzy - Chest pain - Pulmonary edema - Altered Mental Status - Hemodynamically unstable  ECG Findings: - Any underlying cardiac rhythm with a bradycardic rate Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:  Epinephrine 0.01 mg/kg (0.1 ml/kg 1:10,000) IV/IO - q 3 – 5 min  IF NO VASCULAR ACCESS, Epinephrine 0.1 mg/kg (0.1 ml/kg 1:1,000) ET - q 3 – 5 min  Atropine 0.02 mg/kg IV/ET/IO - Minimum single dose 0.1 mg - Maximum single dose 0.5 mg for a pediatric patient - May be repeated x 1 Revision Date 11/01/2005 253 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac BRADYCARDIA PC 03 Page 254 TOC Consult:   Epinephrine Infusion 0.1 – 1 mcg/kg/min If refractory to Epinephrine IV/IO To mix Epinephrine infusion: - 0.6 multiplied by the child’s weight in kg. This amount (in mg) is then added to enough IV solution to equal a total volume of 100 ml. - Infuse at 20 ml/hr via infusion pump until clinical response (increased heart rate OR blood pressure OR improved systemic perfusion) - Reduce infusion to 0.1 to 1 mcg/kg/minute with Baxter Pump - 1 ml/hr equals 1 mcg/kg/minute Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 254 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac HYPOTHERMIA / HYPOTHERMIC ARREST PC 04 Page 255 TOC Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Pulseless - Agonal respirations; apnea - Environmental evidence of hypothermia  ECG Findings: Any pulseless rhythm Assessment:  Cardiac Assessment  Core temperature Primary Interventions: Defibrillation Reference  CPR - BVM ventilation with warm 100% ∼ Defibrillations in progressive order ∼ 2 j/kg O2 Humidified ∼ 4 j/kg - ResQPOD ∼ 4 j/kg - Maintain open airway OPA ∼ NO pulse checks or resumption of CPR in  Intubation between; UNLESS THERE IS  Vascular Access CONVERSION ∼ Do not repeat defibrillation and do not - Use warm fluid medicate if temperature is below 85° F  Warm patient ET Tube Confirmation: - Remove wet clothing ∼ Confirm with 5 methods as per procedure - Heat packs to arm pits and Remove ResQPOD if ROSC occurs groins immediately  If V-Fib: Capnometry Reference: EtCO2 readings consistently > 0 indicate - Biphasic defibrillation tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Secondary Interventions:  Refer to appropriate rhythm protocol for medication reference Consult: Revision Date 02/28/2011 255 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac POST RESUSCITATION MGMT PC 05 Page 256 TOC Criteria and History :    Historical Findings: - Post cardiac arrest Physical Findings: - Patient with spontaneous circulation (palpable carotid/ radial pulse) AFTER being treated for any non-perfusing rhythm ECG Findings: - Any pulseless rhythm Assessment:  Cardiac Assessment Primary Interventions:   O2 via most appropriate method Vascular Access Secondary Interventions:  Lidocaine 1 mg/kg IV/IO - If patient did not previously receive and converted from a ventricular rhythm WITHOUT bradycardia  Lidocaine Infusion 20 – 50 mcg/kg/min - Use IV pump - If patient received Lidocaine prior to ROSC  Fluid Bolus  Naloxone 0.1 mg/kg IV/IO/IN - Max single dose of 2 mg - Rrepeat every 2 – 3 minutes Revision Date 08/01/2007 - Do not administer Naloxone if patient is intubated. Remove ResQPOD if ROSC occurs immediately 256 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac POST RESUSCITATION MGMT PC 05 Page 257 TOC Consult:   Epinephrine Infusion 0.1 – 1 mcg/kg/min If refractory to Epinephrine IV/IO To mix Epinephrine infusion: - 0.6 multiplied by the child’s weight in kg. This amount (in mg) is then added to enough IV solution to equal a total volume of 100 ml. - Infuse at 20 ml/hr via infusion pump until clinical response (increased heart rate OR blood pressure OR improved systemic perfusion) Reduce infusion to 0.1 to 1 mcg/kg/minute with Baxter Pump - 1 ml/hr equals 1 mcg/kg/minute  Sodium Bicarbonate 1 mEq/kg IV/IO - If evidence of metabolic acidosis Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 257 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac NARROW COMPLEX TACHYCARDIA - STABLE PC 06 - A Page 258 TOC Criteria and History :    Historical Findings: - History of SVT - History of A-Fib or A-Flutter Physical Findings: - Hemodynamically stable ECG Findings: - Narrow Complex Tachycardia (refer to assessment chart for rate parameters - QRS < 0.12 seconds) Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Fluid Bolus - May repeat x 2 Secondary Interventions:   Valsalva maneuver by patient Adenosine 0.1 mg/kg mg RAPID IV/IO followed by 10 ml flush - May repeat x 1 as 0.2 mg/kg RAPID IV/IO followed by 10 ml flush of NS Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 258 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac NARROW COMPLEX TACHYCARDIA - UNSTABLE PC 06 - B Page 259 TOC Criteria and History :    Historical Findings: - History of SVT/ use of Adenosine - History of A-Fib or A-Flutter or WPW Physical Findings: - Hemodynamically unstable and/or any of the following:  Chest pain  Dyspnea  Lethargy  Dizziness  Pulmonary edema  AMS EKG Findings: - Narrow Complex Tachycardia (refer to assessment chart for rate parameters QRS < 0.12 seconds) Assessment:  Cardiac Assessment Primary Interventions:  Vascular Access  Synchronized Cardioversion Cardioversion Reference: - 0.5j/kg - 1 j/kg - 2 j/kg - 4 j/kg Secondary Interventions:  Adenosine 0.1 mg/kg RAPID IV/IO followed by 10 ml flush - May repeat x 1 as 0.2 mg/kg RAPID IV/IO followed by 10 ml flush of NS  Midazolam 0.1 mg/kg IV/IM/IO - For sedation prior to cardioversion Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 259 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac PULSELESS ELECTRICAL ACTIVITY PC 07 Page 260 TOC Criteria and History :    Historical Findings: - Medical etiology Physical Findings: - Unconscious - Pulseless - Agonal; apnea ECG Findings: - Pulseless rhythm; not V-fib, VTach, Asystole Assessment:  Cardiac Assessment Primary Interventions:         CPR BVM Ventilation with high-flow O2 ResQPOD Maintain airway with OPA Intubate Vascular Access Fluid Bolus prior to Epinephrine Epinephrine 0.01 mg/kg (0.1 ml/kg 1:10,000) IV/IO - q 3 – 5 min IF NO VASCULAR ACCESS, Epinephrine 0.1 mg/kg (0.1 ml/kg 1:1,000) ET - q 3 – 5 min ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Remove ResQPOD if ROSC occurs immediately Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Secondary Interventions:    Chest Decompression if pneumothorax is present Naloxone 0.1 mg/kg IV/IO/IN - Max single dose of 2 mg - Repeat every 2 – 3 minutes Sodium Bicarbonate 1 mEq/kg IV/IO Revision Date 08/01/2007 Consider all other treatable causes - Hypoxia - ventilation - Hypothermia - warming - Hyperkalemia – calcium gluconate and sodium bicarbonate - Acidosis – ventilation and sodium bicarbonate - Massive MI – heart cath - Hypovolemia/hypotension – fluid replacement - Pulmonary embolism – surgery - Cardiac tamponade – pericardiocentisis 260 Montgomery County Hospital District-EMS PULSELESS ELECTRICAL ACTIVITY Clinical Guidelines – Pediatric Cardiac PC 07 - Page 261 TOC Drug overdose - narcan Tension pneumothorax –chest decompression Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 261 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac NON-TRAUMATIC CHEST PAIN PC 08 Page 262 TOC Criteria and History :    Historical Findings: - Medical etiology Physical Findings: - Chest discomfort - Back, shoulder, neck, jaw, epigastric discomfort - Hemodynamically stable ECG Findings: - No evidence of ischemia or injury Assessment:  Cardiac Assessment Primary Interventions: Identify and treat other causes.   O2 via most appropriate method Vascular Access Secondary Interventions:  Pain Management Consult:  • Ondansetron IV/IM/IO • Weight 8 kg-30 kg 2mg IV/IO/IM/IN • Weight >30kg 4mg IV/IO/IM/IN OR  Ondansetron oral disintegrating tablet (ODT) PO • Weight 8 kg-30 kg 4mg ODT PO • Weight >30kg 8mg ODT PO • May be repeated every 15 min  Promethazine 0.5 mg/kg IV/IO/IM - May be repeated x 1 if N/V persists after 15 minutes - Maximum single dose of 12.5 mg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 262 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac VENTRICULAR ECTOPY PC 09 Page 263 TOC Criteria and History :    Historical Findings: - Medical etioology Physical Findings: - Chest pain with weakness, dizziness, dyspnea, irregular rhythm ECG Findings: - Six or more PVC’s per minute - Multiform PVC’s - Couplets, triplets - Evidence of AMI in the absence of bradycardia Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:  Lidocaine 1 mg/kg IV/IO - q 5 minutes as 0.5 mg/kg up to 3 mg/kg total  Lidocaine Infusion 20 – 50 mcg/kg/min - Use IV pump - If successful conversion of the rhythm with lidocaine bolus Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 263 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Unconscious - Pulseless - Agonal; Apnea  ECG Findings - V- Fib or Pulseless V-Tach Assessment:  Cardiac Assessment VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA PC 10 ∼ ∼ Page 264 TOC Consider all potential non-cardiac causes Remove any secretions, or any vomitus Primary Interventions:          Defibrillation BVM ventilation with 100% O2 ResQPOD Maintain open airway with OPA Continuous CPR Intubate; respiratory rate 8 breaths per minute Vascular Access Epinephrine 0.01 mg/kg (0.1 ml/kg 1:10,000) IV/IO - q 3 – 5 min IF NO VASCULAR ACCESS, Epinephrine 0.1 mg/kg (0.1 ml/kg 1:1,000) ET - q 3 – 5 min Revision Date 02/28/2011 Defibrillation Reference Defibrillation should be done during rotation of compressor to reduce hands off period using the following energy settings: ∼ 2 j/kg ∼ 4 j/kg ∼ 4 j/kg Do not repeat defibrillation and do not medicate if temperature is below 85° F Remove ResQPOD if ROSC occurs immediately ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg 264 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac VENTRICULAR FIBRILLATION/PULSELESS VENTRICULAR TACHYCARDIA PC 10 Page 265 TOC Secondary Interventions:    Lidocaine 1 mg/kg IV/IO/ET Sodium Bicarbonate 1mEq/kg IV/IO Naloxone 0.1 mg/kg IV/IO/IN - Max single dose of 2 mg - Repeat every 2 – 3 minutes ∼ ∼ ∼ ∼ ∼ Only Administer Magnesium Sulfate with: Refractory V-Fib Torsades Des Pointes Naloxone for suspected Drug Overdose Sodium Bicarbonate for Acidosis and TCA overdose Consult:  Amiodarone 5 mg/kg IV/IO - For refractory V-Fib  Magnesium Sulfate 25 – 50 mg/kg IV/IO - For Torsades de Pointes or Hypomagnesia - Maximum dose of 2 grams Critical Points:  If VF or pulseless VT reoccurs after transiently converting, defibrillate at whatever energy level has previously been successful for defibrillation.  Any changes in patient condition, refer to appropriate protocol Revision Date 02/28/2011 265 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac WIDE COMPLEX TACHYCARDIA - STABLE PC 11 - A Page 266 TOC Criteria and History :    Historical Findings: - Medical etiology Physical Findings: - Palpitations ECG Findings: - Ventricular Tachycardia, Wide Complex (QRS > 0.12 seconds) Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:  Lidocaine 1 mg/kg IV/IO - q 5 minutes as 0.5 mg/kg up to 3 mg/kg total  Lidocaine Infusion 20 – 50 mcg/kg/min - Use IV pump - If successful conversion of the rhythm with Lidocaine bolus Consult:  Amiodarone 5 mg/kg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 266 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Cardiac WIDE COMPLEX TACHYCARDIA - UNSTABLE PC 11 - B Page 267 TOC Criteria and History :    Historical Findings: - Medical etiology Physical Findings: - Hemodynamically unstable and/or any of the following:  Chest pain  Dyspnea  Lethargy  Dizziness  Pulmonary edema  AMS ECG Findings: - Wide complex tachycardia Complex (QRS > 0.12 seconds) Assessment:  Cardiac Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Synchronized Cardioversion - 0.5j /kg - 1 j/kg - 2 j/kg - 4 j/kg Cardioversion Reference: - 0.5j/kg - 1 j/kg - 2 j/kg - 4 j/kg Secondary Interventions:  Lidocaine 1 mg/kg IV/IO - q 5 minutes as 0.5 mg/kg up to 3 mg/kg total  Lidocaine Infusion 20 – 50 mcg/kg/min - Use IV pump - If successful conversion of the rhythm with Lidocaine bolus Consult:  Midazolam 0.1 mg/kg IV/IO - For sedation prior to cardioversion Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 267 This Page Intentionally Left Blank PEDIATRIC ENVIRONMENTAL This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Environmental Criteria and History :  Historical Findings: - Exposure to extreme temperatures - Envenomation - Wilderness exposure - Exposure to hazardous materials  Physical Findings: - Hyperthermia/Hypothermia - Altered Mental Status - Shivering - Frostbite - Dyspnea - Evidence of bite, sting, or exposure to chemicals - Nausea/Vomiting - Dizziness/Weakness - Sweating - Abdominal pain Assessment:  C. A. B. C.  Secondary Assessment  Vital Signs  ECG 3-Lead and 12-Lead - Right sided 12-Lead if indicated  Blood glucose  Lung sounds  GCS  OPQRST  ASPN  SAMPLE  Length of Exposure ENVIRONMENTAL ASSESSMENT PE 01 Page 271 TOC Glascow Coma Scale Eye Response Verbal Response Motor Response 4 Spontaneous 5 Orientated 6 Obeys 3 To verbal 4 Confused 5 Localizes 2 To pain 3 Inappropriate 4 Withdraws 1 No response 2 Incomprehensible 3 Flexion 1 No response 2 Extension 1 No response Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 271 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Environmental COLD RELATED EMERGENCY PE 02 Page 272 TOC Criteria and History :  Historical Findings: - Immersion or exposure to cold temperatures  Physical Findings: - Core temperature < 96 degrees F - Shivering - Altered mental status - Cyanosis Assessment:  Environmental Assessment Primary Interventions:    O2 via appropriate method Prevent further heat loss Passive rewarming Passive rewarming: Remove wet clothing Warm blankets Wrap heat packs and apply to axillary and groin regions Secondary Interventions:  Vascular Access Use warm IV fluids For persistent shivering or active seizures, refer to Seizure protocol Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 272 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Environmental Criteria and History :  Historical Findings: - Exposure to heat  Physical Findings: - Environmental potential of heat related emergency - Normothermic or hyperthermic with weakness, dizziness, N/V, syncope, sweating  ECG Findings: - Tachycardia Assessment:  Environmental assessment Primary Interventions:  O2 via most appropriate method  External Cooling Secondary Interventions:  Vascular Access  Fluid Bolus  Trendelenburg Consult:   HEAT RELATED EMERGENCY PE 03 Page 273 TOC Heat Cramps - Cramps in extremities or abdomen Heat Exhaustion - Temperature normal or 1 – 2 degrees above normal with weakness, dizziness, nausea, syncope, profuse sweating, tachycardia Heat Stroke - Temperature of 105 degrees F or greater and any of the following: AMS, Sz activity, lack of sweating, cardiac arrest Remove patient’s clothing Apply cold packs to axillary and groin regions For persistent shivering or active seizures, refer to Seizure protocol Ondansetron oral disintegrating tablet (ODT) PO • Weight 8 kg-30 kg 4mg ODT PO • Weight >30kg 8mg ODT PO • May be repeated every 15 min Promethazine 0.5 mg/kg IV/IO/IM - For N/V - May be repeated x 1 if N/V persists after 15 minutes Revision Date 01/26/2009 273 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Environmental HEAT RELATED EMERGENCY PE 03 Page 274 TOC - Maximum single dose 12.5 mg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 274 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Environmental INSECT / ANIMAL / SNAKE BITE PE 04 Page 275 TOC Criteria and History :  Historical Findings: - Preceding event  Physical Findings: - Pain to location of bite/sting - Known or suspected envenomation by an insect or snake Assessment:  Environmental assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:    Vascular Access Nitrous Oxide (Self-administered) Pain Management For persistent shivering or active seizures, refer to Seizure protocol Consult:  Ondansetron oral disintegrating tablet (ODT) PO • Weight 8 kg-30 kg 4mg ODT PO • Weight >30kg 8mg ODT PO • May be repeated every 15 min  Promethazine 0.5 mg/kg IV/IO/IM - For N/V - May be repeated x 1 if N/V persists after 15 minutes - Maximum single dose 12.5 mg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 275 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Environmental NEAR DROWNING PE 05 Page 276 TOC Criteria and History :  Historical Findings: - Water submersion without cardiopulmonary arrest and without evidence of hypothermia  Physical Findings: - Dysnpea, difficulty breathing Assessment:  Environmental assessment Primary Interventions:  Remove from water  O2 via most appropriate method  Intubate - If unconscious and unable to protect airway  Capnography  External warming  Vascular Access ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Secondary Interventions:   Tracheal suctioning via ETT PEEP usage during ventilation  Consider RSI - See Pediatric RSI Procedure Acceptable PEEP limits: 2 – 5 cm Consult: Mallampati Classification Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 276 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Environmental TOXICOLOGICAL / HAZ-MAT EXPOSURE PE 06 Page 277 TOC Criteria and History :  Historical Findings: - Determine type of exposure & refer to USDOT-ERG for initial assessment and management.  Physical Findings: - Findings will vary based upon contaminant.  If Organophosphates (OGP’s) SLUDGE-BM - Salivation, Lacrimation (Tearing), Urination, Diarrhea/Defecation, GI Distress, Emesis, Bradycardia, & Miosis (Pinpoint pupils) Assessment:    Ensure that the patient has been decontaminated. At NO TIME SHOULD EMS personnel enter the HOT or WARM Zone, unless wearing appropriate PPE. If exposure is localized and not generalized: - Dry Chemical: Brush the chemical off and flush with copious amounts of water. - Wet Chemical: Irrigate with copious amounts of water. Hazardous Materials may fall under the following categories: • Chemical • Biological • Nuclear • Radioactive • Explosive Most common OGP’s are pesticides and produce an exaggerated parasympathetic response. Medical Care should be coordinated with a Hazardous Materials Response Team Appropriate PPE may be either Level B partially encapsulated suits with PAPR (Positive Air Purifying Respirators) or Level A Fully encapsulated suits with SCBA. Water should be from a steady stream, for at least 15 – 20 minutes into a sanitary sewer Primary Interventions:     Assure scene and personal safety. Assure that patient has been decontaminated appropriately. Provide for oxygenation and ensure patent airway Vascular Access Revision Date 11/01/2005 277 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Environmental TOXICOLOGICAL / HAZ-MAT EXPOSURE PE 06 Page 278 TOC Secondary Interventions:   Evaluate ECG as appropriate For OGP, administer Atropine 1 mg repeated frequently until Bradycardia has resolved.  RSI - See Pediatric RSI Procedure Doses in excessive of Atropine 0.02 mg/kg may be required to resolve Bradycardia in OGP. Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 278 This Page Intentionally Left Blank 279 PEDIATRIC MEDICAL This Page Intentionally Left Blank Montgomery County Hospital District-EMS MEDICAL ASSESSMENT Clinical Guidelines – Pediatric Medical PM 01 Page 282 TOC Criteria and History :   Historical Findings: - Recent events - PMHx Physical Findings: - Pain - Non-traumatic hemorrhage - Itching, swelling, hives - Altered mental status - Fever - Headache Assessment:           C. A. B. C. Secondary Assessment Vital Signs (orthostatic) ECG 3-Lead and 12-Lead - Right sided 12-Lead if indicated Blood glucose Lung sounds GCS OPQRST ASPN SAMPLE Revision Date 11/01/2005 282 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical ALLERGIC REACTION PM 02 Page 283 TOC Criteria and History :   Historical Findings: - Medical etiology - Exposure to allergen Physical Findings: - Mild Reaction – contact dermatitis (rash) and/or urticaria (hives), dermal itching - Moderate Reaction – mild reaction symptoms with dyspnea - Anaphylaxis – severe reaction symptoms with hypotension, difficulty swallowing, generalized edema, stridor Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions: Mild:  Vascular Access  Diphenhydramine 1 mg/kg IV/IO/IM - Max single dose of 25 mg Moderate:  “Mild reaction” treatment in addition to:  Xopenex 1.25 mg/3 ml by nebulizer  Xopenex 0.63 mg/3 ml by nebulizer for children < 4 years old  Methylprednisolone 2 mg/kg IV/IO OR  Decadron 0.2 – 0.5 mg/kg IV/IO may repeat x 2 in 15 minutes  Epinephrine 1:1,000 0.01 mg/kg IM up to 0.3 mg Revision Date 03/28/2011 Methylprednisolone Dosing Chart Methylprednisolone is packaged 125 mg / 2ml Weight (kg) 5 10 15 20 25 30 35 40 45 50 55 60 65 Dose (mg) 10 20 30 40 50 60 70 80 90 100 110 120 130 Volume (ml) 0.16 0.32 0.48 0.64 0.80 0.96 1.1 1.3 1.4 1.6 1.8 1.9 2.1 283 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical ALLERGIC REACTION PM 02 Page 284 TOC Anaphylaxis  “Moderate reaction” treatment in addition to:  Epinephrine 1:10,000 0.01 mg/kg IV/IO  Epinephrine 1:1,000 0.01 mg/kg IM - Maximum dose of 0.3 mg Consult:     Continued age appropriate Xopenex dose - If beneficial response is seen Epinephrine 1:10,000 0.01 mg/kg IV/IO - If not resolved Epinephrine 1:1,000 0.01 mg/kg SL - If patient is obtunded or unconscious and vascular access cannot be established rapidly - Inject directly into the sublingual tissue Consider RSI - See Pediatric RSI Procedure Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 03/28/2011 284 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical AMS / UNCONSCIOUS PM 03 Page 285 TOC Criteria and History :   Historical Findings: - Medical etiology Physical Findings: - Unresponsive, disoriented WITHOUT a clear mechanism for AMS Consider causes: - CVA - Hypoglycemia/hyperglycemia - Drug/ Alcohol use - Recent trauma - Hepatic disease - Acidosis/electrolyte imbalance - Sepsis - Hypotension - Hypoxemia Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:   Vascular Access Naloxone 0.1 mg/kg IV/IO/IN - Max single dose of 2 mg - Repeat every 2 – 3 minutes - Do not administer Naloxone if pt is intubated  RSI - See Pediatric RSI Procedure Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 285 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical DEHYDRATION PM 04 Page 286 TOC Criteria and History :  Historical Findings: - Recent illness (vomiting, diarrhea, fever)  Physical Findings: - Poor Skin turgor - Little or no urine output - Dry mucous membranes Assessment: Compensated Hypovolemia - Normotension and tachycardia Uncompensated Hypovolemia - Hypotension and tachycardia  Medical Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access Secondary Interventions:  Fluid Bolus - May repeat x 2 to maintain adequate B/P - If patient condition improves repeat fluid bolus unless patient develops pulmonary edema Consult:   Ondansetron oral disintegrating tablet (ODT) PO • Weight 8 kg-30 kg 4mg ODT PO • Weight >30kg 8mg ODT PO • May be repeated every 15 min Promethazine 0.5 mg/kg IV/IO/IM - For N/V - May be repeated x 1 if N/V persists after 15 minutes - Maximum single dose 12.5 mg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 286 Montgomery County Hospital District-EMS DIABETIC - HYPERGLYCEMIA Clinical Guidelines – Pediatric Medical PM 05 - A Page 287 TOC Criteria and History :   Historical Findings: - Medical etiology Physical Findings: - BGL > 180 mg/dL with one of the following: - AMS, tachypnea, abdominal pain, Hypotension and tachycardia Blood glucose < 80 refer to hypoglycemia protocol Blood glucose < 40 in the neonate (<1 month old) refer to hypoglycemia protocol Assessment:  Medical Assessment Primary Interventions:    O2 via most appropriate method Vascular Access Fluid Bolus - May repeat x 2 - Maintenance infusion 20 ml/kg with Baxter Pump Secondary Interventions: Consult:  Ondansetron oral disintegrating tablet (ODT) PO • Weight 8 kg-30 kg 4mg ODT PO • Weight >30kg 8mg ODT PO • May be repeated every 15 min  Promethazine 0.5 mg/kg IV/IO/IM - For N/V - May be repeated x 1 if N/V persists after 15 minutes - Maximum single dose 12.5 mg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 287 Montgomery County Hospital District-EMS DIABETIC - HYPOGLYCEMIA Clinical Guidelines – Pediatric Medical PM 05 - B Page 288 TOC Criteria and History :  Historical Findings: - Known history - New onset  Physical Findings: - BGL < 80 mg/dL ( < 40 mg/dL for newborns) - Signs and symptoms suggestive of Hypoglycemia: AMS, tremors, weakness, N/V, intense hunger, diaphoresis BGL < 40 mg/dL should be treated, regardless of presence of other signs/symptoms Assessment:  Medical Assessment Primary Interventions:   O2 via most appropriate method Vascular Access - Do Not delay transport to establish Secondary Interventions:  Oral Glucose 7.5 – 15 g  D50% 0.5 g/kg IV for children > 10 kg or 2 years of age OR  D25% 0.5 g/kg IV for infants < 10 kg - May be repeated once in 5 min if symptoms not resolved - Repeat BG in 10 min after D50%/D25% administration  Thiamine 10 – 25 mg IV/IO or IM Oral Glucose - In minimally symptomatic patients who are old enough and capable of taking oral glucose solutions - Able to follow commands Thiamine - For older children/teenagers with a significant history of alcohol use/abuse or malnourished children Consult:  Repeat D50%/D25% administration if continued evidence of hypoglycemia on basis of persistent symptoms and glucometer reading  Glucagon 0.5 mg IM/SQ if unable to obtain vascular access Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 288 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical DYSTONIC REACTION PM 06 Page 289 TOC Criteria and History :  Historical Findings: - Recent ingestion of phenothiazines, fluphenazines, other neuroleptics or related drugs used as antipsychotics and also to treat GI disorders and nausea  Physical Findings: - Protrusion of the tongue, twisted neck or facial spasms, roving or deviated gaze, abdominal rigidity or pain, spasm of the entire body, twitching Assessment: Promethazine Reglan (Metoclopramide Propulsid Haldol  Medical Assessment Primary Interventions:    O2 via most appropriate method Vascular Access Diphenhydramine 1 mg/kg IV/IM/IO - Max single dose of 25 mg Secondary Interventions: Consult:  Midazolam 0.1 mg/kg IV/IM/IO if no response is seen from Diphenhydramine Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 289 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical FEVER PM 07 Page 290 TOC Criteria and History :  Historical Findings: - Evidence of determinable source for sepsis  Physical Findings: - AMS - Weakness - Temperature > 101 degrees F Assessment:  - Use of full PPE is recommended Medical Assessment Primary Interventions:  O2 via most appropriate method  Vascular Access  Acetaminophen – refer to dosing chart  Ibuprofen – refer to dosing chart Secondary Interventions:   Fluid Bolus - May repeat x 2 External cooling Remove patient’s clothing Apply cold packs to axillary and groin regions Avoid excessive cooling For persistent shivering or active seizures, refer to Seizure protocol Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 290 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical NON-TRAUMATIC ABDOMINAL PAIN PM 08 Page 291 TOC Criteria and History :   Historical Findings: - Medical etiology Physical Findings: - Abdominal pain with rebound tenderness, increased pain on palpation, increased pain on movement Abdominal pain secondary to trauma is managed with the Multi-system trauma protocol. Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:   Vascular Access Fluid Bolus - If hypotensive and/or signs of hypoperfusion - May repeat x 2 Consult:  Ondansetron oral disintegrating tablet (ODT) PO • Weight 8 kg-30 kg 4mg ODT PO • Weight >30kg 8mg ODT PO • May be repeated every 15 min  Promethazine 0.5 mg/kg IV/IO/IM - For N/V - May be repeated x 1 if N/V persists after 15 minutes - Maximum single dose 12.5 mg  Repeat Fluid Bolus Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 291 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical Criteria and History :  Historical Findings: - Medical etiology  Physical Findings: - Hypovolemia secondary to blood loss due to medical etiology “Coffee ground” emesis - Blood in stool - Epistaxis NON-TRAUMATIC HEMORRHAGE PM 09 Page 292 TOC Consider all possible causes - Abdominal aortic aneurysm (AAA) - Ulcers/Diverticulitis/GI bleed Assessment:  Medical Assessment Primary Interventions:   O2 via most appropriate method Vascular Access Secondary Interventions:  Fluid Bolus x 2 q 5 minutes - Discontinue if pulmonary edema develops  Consider Trendelenburg Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 292 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical NON-TRAUMATIC SHOCK / HYPOTENSION PM 10 Page 293 TOC Criteria and History :   Historical Findings: - No evidence of blood loss or trauma Physical Findings: - Hemodynamically unstable - AMS - Sepsis - Tachycardia Evidence of sepsis can include any of the following:  Fever  Recent wound or surgery  Recent URI/UTI symptoms  Urinary catheter  Petechia or rash Assessment:  Cardiac Assessment Primary Interventions:   O2 via most appropriate method Vascular Access Secondary Interventions:  Vascular Access - Do Not delay transport to accomplish  Fluid Bolus - May repeat x 2 Consult:  Consider need for RSI  Epinephrine Infusion 0.1 – 1 mcg/kg/min  If refractory to Epinephrine IV/IO To mix Epinephrine infusion: - 0.6 multiplied by the child’s weight in kg. This amount (in mg) is then added to enough IV solution to equal a total volume of 100 ml. - Infuse at 20 ml/hr via infusion pump until clinical response (increased heart rate OR blood pressure OR improved systemic perfusion) - Reduce infusion to 0.1 to 1 mcg/kg/minute with Baxter Pump - 1 ml/hr equals 1 mcg/kg/minute Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 293 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical OVERDOSE / POISONING PM 11 Page 294 TOC Criteria and History :  Historical Findings: - Known or suspected ingestion or injection of pharmacoactive substance, whether intentional or accidental - Ingestion, inhalation or absorption of potentially harmful non-pharmaceutical substance  Physical Findings: - Lethargy, Altered Mental Status, combative, unresponsive Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method 100% O2 for Carbon monoxide Consider Hyperbaric Therapy Secondary Interventions:      Vascular Access Naloxone 0.1 mg/kg IV/IO/IN - Max single dose of 2 mg - Repeat every 2 – 3 minutes Sodium Bicarbonate 0.5 – 1 mEq/kg IV/IO - For known Tricyclic Antidepressant OD IF - Wide QRS > 0.12 sec - Infant 0 – 1 year receive 4.2% Sodium Bicarbonate - Child 1 – 8 year receive 8.4% Sodium Bicarbonate - Ethylene glycol ingestion (Antifreeze, De-Icing agents, Paints, Detergents) Atropine 0.02 mg/kg IV/IM/IO - For Organophosphate Poisoning With parasympathetic symptoms - q 5 minutes as needed - Do Not administer Naloxone if patient is intubated Consider consult with physician at receiving facility Revision Date 08/01/2007 294 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical  OVERDOSE / POISONING PM 11 Page 295 TOC Consider contacting Poison control (1-800-POISON-1 or 1-800-7647661) Consult:  Charcoal PO if oral Overdose - 1 g/kg if < 1 yr. old - 25 – 50 g if age 1 –12 yr. - May mix with juice or water Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 295 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical SEIZURES PM 12 Page 296 TOC Criteria and History :   Historical Findings: - History of seizures - Head trauma - New onset Physical Findings: - Post-ictal  Witnessed, reported or suspected seizure prior to EMS arrival - Active  Actively seizing patient upon EMS arrival Assessment:  Medical Assessment Consider possible causes: - Febrile - Epilepsy - Overdose - Withdrawals - Hypoglycemia Primary Interventions:  O2 via most appropriate method  Vascular Access - If prolonged post-ictal state - If need for IV/IO meds - Do Not delay transport to accomplish Secondary Interventions:  Midazolam 0.1 mg/kg IV/IM/IO/IN for ACTIVE seizures - Max. dose 5 mg – if patient < 2 years - Max. dose 10 mg – if patient > 10 years Revision Date 08/01/2007 For Fever, refer to Fever protocol 296 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical SEIZURES PM 12 Page 297 TOC Consult:     Diazepam 0.2 – 0.3 mg/kg IV/IO for ACTIVE seizures Diazepam 0.4 – 0.6 mg/kg PR for ACTIVE seizures and unable to establish IV Naloxone 0.1 mg/kg IV/IO/IN - Do Not administer Naloxone if patient is - Max single dose of 2 mg intubated - Repeat every 2 – 3 minutes RSI - For status seizures Mallampati Classification: - See RSI Pediatric Procedure Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 297 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Medical SYNCOPE PM 13 Page 298 TOC Criteria and History :   Historical Findings: - History of loss of consciousness Physical Findings: - Common “faint” (vasovagal syncope) - Postural “faint” (orthostatic syncope) - Hyperventilation syncope Assessment:  Medical Assessment Primary Interventions:  O2 via most appropriate method  Once you have completed a patient assessment, and a cause of syncope has been determined, refer to the appropriate protocol. Secondary Interventions:  Vascular Access Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 298 This Page Intentionally Left Blank Revision Date 11/01/2005 299 PEDIATRIC RESPIRATORY This Page Intentionally Left Blank Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory RESPIRATORY ASSESSMENT PR 01 Page 302 TOC Criteria and History :   Historical Findings: - Use of inhaled medications, steroids - Fever - Productive cough - Recent surgery Physical Findings: - Dyspnea, tachypnea - Cyanosis - Edema - Wheezing, rales, rhonchi, absent/decreased breath sounds, grunting, stridor - Use of accessory muscles, grunting - Chest pain - Bronchoconstriction Consider all possible causes and refer to appropriate protocol - Pulmonary Embolism - Anxiety - Asthma - Airway obstruction - Pneumonia - Pneumothorax - Allergic reaction - Aspiration Assessment: Mallampati Classification: C. A. B. C. Class I: soft palate, fauces, uvula, pillars visible Secondary Assessment Class II: soft palate, fauces and uvula visible Vital Signs Class III: soft palate, base of uvula visible ECG 3-Lead and 12-Lead Class IV: soft palate not visible - Right sided 12-Lead if indicated  Blood glucose  Lung sounds  GCS  OPQRST  ASPN  SAMPLE  Mallampati score Critical Points:  Any changes in patient condition, refer to appropriate protocol     Revision Date 11/01/2005 302 Montgomery County Hospital District-EMS AIRWAY OBSTRUCTION Clinical Guidelines – Pediatric Respiratory PR 02 Page 303 TOC Criteria and History :  Physical Findings: - Partial or complete airway obstruction - Secondary to foreign body aspiration - Decreased LOC - Cyanosis - Obvious inadequate air exchange Assessment:  Respiratory assessment Primary Interventions:  Abdominal/chest thrusts - If patient is conscious  Direct laryngoscopy and removal of foreign object with Magill forceps or suction - If patient is unconscious and there is a complete obstruction  O2 via most appropriate method Secondary Interventions:  Responsive Infant: Back blows and chest thrusts Responsive Child: Abdominal (Heimlich) thrusts Vascular Access Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 303 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory BRONCHOSPASM PR 03 Page 304 TOC Criteria and History :   Historical Findings: - History of asthma Physical Findings: - Dyspnea with wheezing or prolonged expiratory phase Assessment:  Respiratory assessment Primary Interventions:    O2 via most appropriate method Vascular Access Fluid Bolus Secondary Interventions:  Xopenex 1.25 mg/3 ml by nebulizer - For mild/moderate dyspnea - May repeat x 2 in 15 minutes  Xopenex 0.63 mg/3 ml by nebulizer - For children < 4 years of age - May be repeated x 2 in 15 minute  Methylprednisolone 2 mg/kg IV/IO OR  Decadron 0.2 – 0.5 mg/kg IV/IO Revision Date 03/28/2011 Methylprednisolone Dosing Chart Methylprednisolone is packaged 125 mg / 2ml Weight (kg) 5 10 15 20 25 30 35 40 45 50 55 60 65 Dose (mg) 10 20 30 40 50 60 70 80 90 100 110 120 130 Volume (ml) 0.16 0.32 0.48 0.64 0.80 0.96 1.1 1.3 1.4 1.6 1.8 1.9 2.1 304 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory BRONCHOSPASM PR 03 Page 305 TOC Consult:     Continued Xopenex treatment for appropriate age - If beneficial response is seen Epinephrine 1:1,000 0.01 mg/kg (0.01 ml/kg) IM - For severe dyspnea or near respiratory failure - Max single dose 0.3 mg Repeat Epinephrine 1:1,000 0.01 mg/kg (0.01 ml/kg) IM - If no relief of dyspnea RSI - See Pediatric RSI Procedure Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 03/28/2011 305 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory CROUP PR 04 Page 306 TOC Criteria and History:  Historical Findings: - History of recent upper respiratory illness  Physical Findings: - Difficulty breathing with barking cough - Dyspnea - Inspiratory stridor - Recent history or current symptoms of URI - Croup is a viral infection usually seen in children 18 months – 3 years of age Assessment:  Respiratory assessment Primary Interventions:  O2 via most appropriate method humidified  It is IMPERATIVE that oxygen administration not result in increased agitation. Allow parent to assist with administration. Secondary Interventions:    Vascular Access Fluid Bolus Xopenex 1.25 mg/3 ml by nebulizer - For mild/moderate dyspnea - May repeat x 2 in 15 minutes  Xopenex 0.63 mg/3 ml by nebulizer - For children < 4 years of age - May be repeated x 2 in 15 minute  Methylprednisolone 2 mg/kg IV OR  Decadron 0.2 – 0.5 mg/kg IV Consult: Critical Points: Revision Date 11/01/2005 306 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory  CROUP PR 04 Page 307 TOC Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 307 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory EPIGLOTTIS PR 05 Page 308 TOC Criteria and History:  Historical Findings: - History of recent upper respiratory illness  Physical Findings: - Dyspnea - Evidence of upper airway obstruction (inspiratory stridor, drooling, or hoarseness) Any one or more of the following: - Fever - Recent history of URI symptoms - Dysphasia or severe sore throat - Drooling - Epiglotitis is a bacterial infection often seen in children 3 – 7 years of age Assessment:  Respiratory assessment Primary Interventions:  O2 via most appropriate method – humidified  TRANSPORT ASAP in a position of comfort, usually sitting upright    It is IMPERATIVE that oxygen administration not result in increased agitation. Allow parent to assist with administration. DO NOT attempt an IV or airway manipulation unless COMPLETE airway obstruction occurs Pre-oxygenate patient with BVM and 100% Oxygen prior to intubation attempt Secondary Interventions:   Vascular Access Fluid Bolus Consult: Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 308 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory PNEUMONIA PR 06 Page 309 TOC Criteria and History :  Historical Findings: - Recent upper respiratory illness  Physical Findings: - Fever - Productive cough - Wheezing, rhonchi or rales Assessment:  Respiratory assessment Primary Interventions:     O2 Via most appropriate method Vascular Access Xopenex 1.25 mg/3 ml by nebulizer - For mild/moderate dyspnea - May repeat x 2 in 15 minutes Xopenex 0.63 mg/3 ml by nebulizer - For children < 4 years of age - May be repeated x 2 in 15 min Secondary Interventions:  Fluid Bolus For Fever, refer to Fever protocol Consult:  RSI - See Pediatric RSI Procedure Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points: Revision Date 11/01/2005 309 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory  PNEUMONIA PR 06 Page 310 TOC Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 310 Montgomery County Hospital District-EMS RESPIRATORY DISTRESS Clinical Guidelines – Pediatric Respiratory PR 07 Page 311 TOC Criteria and History :   Historical Findings: - New onset - Pre-existing condition Physical Findings: - Dyspnea without a clear etiology - Increased respiratory effort Assessment:  Respiratory assessment Primary Interventions:  O2 via most appropriate method Secondary Interventions:  Vascular Access  Xopenex 1.25 mg/ 3 ml by nebulizer - For mild/moderate dyspnea  Xopenex 0.63 mg/ 3 ml by nebulizer - For children < 4 years of age If no beneficial response seen with Xopenex, consider other causes and treatment. Consult:   Xopenex 1.25 mg / 3 ml by nebulizer RSI if appropriate - See Pediatric RSI Procedure Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 311 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory RESPIRATORY FAILURE / SHOCK PR 08 Page 312 TOC Criteria and History :   Historical Findings: - No evidence of blood loss or trauma Physical Findings: - Failure to oxygenate or ventilate or both Respiratory Failure: - Dyspnea (Tachypnea or Bradypnea, accessory muscle use ) - Cyanosis or - Agitation / Obtundation - Nasal Flaring - Grunting Shock: - Apathy and listlessness - Diminished peripheral pulses - Prolonged capillary refill - Cool, pale, or mottled skin - Doesn’t respond to parents or painful stimuli Assessment:  Medical assessment Primary Interventions:  O2 via most appropriate method  Vascular Access - Do Not delay transport to accomplish  Fluid Bolus - May repeat x 2 unless pulmonary edema develops Secondary Interventions: Revision Date 11/01/2005 312 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Respiratory RESPIRATORY FAILURE / SHOCK PR 08 Page 313 TOC Consult:   RSI - See Pediatric RSI Procedure Chest Decompression - If pneumothorax suspected If narcotic overdose is suspected, see Overdose\Poisoning Protocol Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/01/2005 313 PEDIATRIC TRAUMA This Page Intentionally Left Blank Montgomery County Hospital District-EMS TRAUMA ASSESSMENT Clinical Guidelines – Pediatric Trauma PT 01 Criteria and History:  Historical Findings: - History of recent trauma - MOI indicative of trauma  Physical Findings: Evidence of trauma Assessment:  C. A. B. C.  Physical exam - Focused or rapid trauma assessment  Vital Signs  ECG 3-Lead and 12-Lead - Right sided 12-Lead if indicated  Blood glucose  Lung sounds  GCS  OPQRST  ASPN  SAMPLE  Pediatric Trauma Score Revision Date 11/01/2005 Page 316 TOC Glascow Coma Scale Eye Response Verbal Response Motor Response 4 Spontaneous 5 Orientated 6 Obeys 3 To verbal 4 Confused 5 Localizes 2 To pain 3 Inappropriate 4 Withdraws 1 No response 2 Incomprehensible 3 Flexion 1 No response 2 Extension 1 No response 316 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma AMPUTATION PT 02 Page 317 TOC Criteria and History :  Historical Findings: - Mechanism of injury  Physical Findings: - A severed part that is completely separated from the body Assessment:  Trauma assessment Primary Interventions:    O2 via most appropriate method Control hemorrhage Vascular Access - Fluid Bolus if severe blood loss has occurred Secondary Interventions:  Consider pressure points or a tourniquet. - If hemorrhage can not be controlled:  Splint any associated Fractures / Dislocations  Rinse amputated part with sterile water, placed in a bag and kept cool. DO NOT: - Soak in water - Cover with wet gauze or towels - Place directly on ice  Nitrous Oxide (Self-administered)  Pain Management Consult:  Ondansetron oral disintegrating tablet (ODT) PO • Weight 8 kg-30 kg 4mg ODT PO • Weight >30kg 8mg ODT PO • May be repeated every 15 min  Promethazine 0.5 mg/kg IV/IO/IM - For N/V - May be repeated x 1 if N/V persists after 15 minutes - Maximum single dose 12.5 mg Revision Date 01/26/2009 To care for amputated part Rinse with sterile water Place in a bag Keep cool but do not place directly on ice Consider pressure points or tourniquet if hemorrhage cannot be controlled by direct pressure 317 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma AMPUTATION PT 02 Page 318 TOC Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 318 Montgomery County Hospital District-EMS BURNS Clinical Guidelines – Pediatric Trauma PT 03 Page 319 TOC Criteria and History :   Historical Findings: - Mechanism of injury Physical Findings: Tissue injury from direct contact with: - Heat source - Chemical reaction - Inhalation - Electrical / lightning contact Inhalation Injuries/Burns with any one of the following: - Singed nasal hairs or oral mucosa. - Erythema of the palate, soot in the mouth, larynx or sputum. - Rapid, shallow ventilation with tachypnea of >40 AND decreased mental status. - Respiratory rate < 14 in pediatric patient - Mechanical airway obstruction from trauma, edema, or laryngospasm. - Signs of respiratory distress such as nasal flaring, respiratory crowing or stridor, anxiety, agitation, or combativeness. - Edema associated with a burn of the face or neck. - Unconsciousness. Assessment: Rule of Nines: refer to appendix  Trauma assessment Primary Interventions:     - Remove the burn source O2 via most appropriate method Vascular Access Intubation for respiratory burns Secondary Interventions:  Treat Underlying Injuries  Dress burns as follows - TBSA < 15% use burn gel - TBSA > 15% use dry sterile dressing or burn sheet  Nitrous Oxide (Self-administered) - If no inhalation/respiratory burns  Pain Management  All other injuries should be treated en-route to the hospital if feasible Revision Date 08/01/2007 - - - Remove jewelry and resticting clothing Brush off any powdered chemical Irrigate chemical burn site with water, if appropriate to chemical V (fluids volume)= TBSA of burn (%) x weight (kg) x 4 Do not administer MS to patients with severe respiratory burns unless airway is secured Keep the patient warm after removing burn source and possibly contaminated clothing 319 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma BURNS PT 03 Page 320 TOC Any changes in condition/rhythm refer to appropriate Pediatric Protocol Consult:  RSI - If needed for Intubation Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol  Appropriate Destination : UTMB or Hermann Hospital - For inhalation / hands; - >30% TBSA 2nd degree and/or higher; - or <12 and > 65 years of age Revision Date 08/01/2007 320 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma EVISCERATION PT 04 Page 321 TOC Criteria and History :  Historical Findings: - Mechanism of injury  Physical Findings: - Protrusion of internal organs through a wound Assessment:  Trauma assessment Primary Interventions:    Spinal motion restriction if indicated O2 via most appropriate method Occlude wound with a sterile, moist dressing and bandage Secondary Interventions:   Vascular Access Pain Management Consult: Critical Points:  Any changes in patient condition refer to appropriate protocol Revision Date 08/01/2007 321 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma EYE INJURY PT 05 Page 322 TOC Criteria and History :   Historical Findings: - Decreased or loss of vision - Mechanism of injury Physical Findings: - Injury to the globe, open or closed, including:  Corneal abrasion  Foreign body in eye  Chemical bum  Lacerated or avulsed globe  "Arc" burn of globe - Excessive tearing and burning of the eyes, nasal drainage, salivation Assessment:  Trauma assessment Primary Interventions:   Spinal motion restriction if indicated Dress and bandage wound as appropriate Secondary Interventions:  IF chemical bum: - Flush continuously with NS  IF open injury to globe: - Shield both eyes  IF corneal abrasion, arc bum, or foreign body: - Tetracaine 1 – 2 gtt in affected eye Repeat as needed - Remove foreign body if globe not penetrated - Shield affected eye  Vascular Access - If severe pain or nausea and/or vomiting present and able to accomplish without increasing Intraocular pressure  Nitrous Oxide (Self-administered)  Pain Management Consult:  Ondansetron oral disintegrating tablet (ODT) PO • Weight 8 kg-30 kg 4mg ODT PO • Weight >30kg 8mg ODT PO • May be repeated every 15 min  Promethazine 0.5 mg/kg IV/IO/IM - For N/V - May be repeated x 1 if N/V Revision Date 01/26/2009 322 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma - EYE INJURY PT 05 Page 323 TOC persists after 15 minutes Maximum single dose 12.5 mg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 323 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma HEAD TRAUMA PT 06 Page 324 TOC Criteria and History :  Historical Findings: - Recent event - Mechanism of injury  Physical Findings: - Altered mental status - Loss of consciousness Assessment:  Glascow Coma Scale Trauma assessment Eye Response Verbal Response Motor Response 4 Spontaneous 5 Orientated 6 Obeys 3 To verbal 4 Confused 5 Localizes 2 To pain 3 Inappropriate 4 Withdraws 1 No response 2 Incomprehensible 3 Flexion 1 No response 2 Extension 1 No response Primary Interventions:    Spinal Motion Restriction O2 via most appropriate method Inline intubation, if needed Secondary Interventions:  Helmet Removal - For airway management if clinically indicated  Vascular Access  Fluid Bolus - Repeat x 1 Revision Date 08/01/2007 If patient is hypotensive, look for and treat other injuries as well Helmet Removal Maintain neutral alignment with padding as needed after removal 324 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma HEAD TRAUMA PT 06 Page 325 TOC Consult:  RSI if appropriate - See Pediatric RSI Procedure Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Rapid transport to appropriate facility is crucial  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 325 Montgomery County Hospital District-EMS MULTI-SYSTEM TRAUMA Clinical Guidelines – Pediatric Trauma PT 07 Page 326 TOC Criteria and History :  Historical Findings: - Mechanism of injury  Physical Findings: - Injury to the chest, abdomen or pelvis - Multiple soft-tissue or musculo-skeletal injuries Assessment:  Trauma assessment Primary Interventions:     Spinal Motion Restriction O2 via most appropriate method Inline intubation, if needed Occlude open chest wounds Secondary Interventions:  Vascular Access - Enroute  Fluid Bolus - Repeat as needed unless pulmonary edema develops  Any changes in condition/rhythm refer to appropriate Pediatric Protocol All other injuries should be treated en-route to the hospital if feasible Consult: Mallampati Classification:  RSI if appropriate Class I: soft palate, fauces, uvula, pillars visible - See Pediatric RSI Procedure Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: - EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 08/01/2007 326 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma MUSCULOSKELETAL – SOFT TISSUE INJURY PT 08 Page 327 TOC Criteria and History :  Historical Findings: - Mechanism of injury  Physical Findings: - Pain on palpation or movement - Ecchymosis, swelling, deformity Assessment:  Trauma assessment Primary Interventions:     O2 via most appropriate method Spinal motion restriction Control hemorrhage Splint Check CMS before and after applying splint Secondary Interventions:  Vascular Access if: - Open fracture - Femur fracture - Pelvic fracture/Hip dislocation - Signs of hypotension and/or hypoperfusion  Cooling of injury site  Nitrous Oxide (Self-administered)  Pain Management Consult:  C-spine clearance  Fracture reduction by inline traction if no pulse is detected and if is a closed fracture - If still no pulse, splint in position  Ondansetron oral disintegrating tablet (ODT) PO • Weight 8 kg-30 kg 4mg ODT PO • Weight >30kg 8mg ODT PO • May be repeated every 15 min  Promethazine 0.5 mg/kg IV/IO/IM - For N/V - May be repeated x 1 if N/V persists after 15 minutes - Maximum single dose 12.5 mg Revision Date 01/26/2009 327 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma MUSCULOSKELETAL – SOFT TISSUE INJURY PT 08 Page 328 TOC Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 01/26/2009 328 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma PENETRATING INJURY PT 09 Page 329 TOC Criteria and History :  Historical Findings: - Mechanism of injury - Note ballistics  Physical Findings: - A penetrating injury to any body part - Entrance / exit wounds Assessment:  Trauma assessment Primary Interventions:  O2 via most appropriate method  Occlude chest wounds  Control hemorrhage  Vascular Access  Spinal Motion Restriction  Chest decompression as needed Secondary Interventions:    Stabilize impaled objects Bandage and dress open wounds Pain Management Consult: Critical Points:  Any change in patient condition refer to appropriate protocol Revision Date 08/01/2007 329 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma SEXUAL ASSAULT PT 10 Page 330 TOC Criteria and History :  Historical Findings: - Report of recent sexual assault  Physical Findings: - Signs of assault or injury Assessment:  Trauma assessment Primary Interventions:    Assure scene and personal safety Provide emotional support O2 via most appropriate method Do not let patient bathe or change clothing. Collect any pertinent items in an unused biohazard bag, and transport with the patient. Any blankets or sheets used by or on patient during transport should accompany patient into the receiving facility. In the event of hostile family or caregivers, avoid confrontations that might interfere with removing patient from the environment. Secondary Interventions:  Treat underlying injuries Consult: Critical Points:  Any changes in patient condition refer to appropriate protocol  Appropriate destination: Texas Children’s Hospital  Refer to appropriate protocol for specific injuries or conditions. Revision Date 11/01/2005 330 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma SPINAL TRAUMA PT 11 Page 331 TOC Criteria and History :  Historical Findings: - Mechanism of injury  Physical Findings: - Presence of decreased neurological function below site of injury - Loss of sensation - Inability to move Hypotension Assessment:  Trauma assessment Primary Interventions:   Spinal Motion Restriction O2 via most appropriate method Secondary Interventions:  Vascular Access - Fluid Bolus if neurogenic shock is present or anticipated - Repeat x 2 if no signs of pulmonary edema  RSI if appropriate - See Pediatric RSI Procedure Consult: Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Critical Points:  Any change in patient condition refer to appropriate protocol - Transport to appropriate facility Revision Date 11/01/2005 331 Montgomery County Hospital District-EMS Clinical Guidelines – Pediatric Trauma TRAUMATIC ARREST PT 12 Page 332 TOC Criteria and History :  Historical Findings: - Underlying multi-system trauma - Surgical problem  Physical Findings: - Multi-system trauma  ECG Findings: - Any non-perfusing rhythm Assessment:  Trauma assessment Primary Interventions:      CPR - BVM ventilation with 100% O2 - Maintain open airway with OPA Inline intubation Spinal Motion Restriction Chest Decompression - If signs/symptoms of tension pneumothorax Occlude open chest wounds Mallampati Classification: Class I: soft palate, fauces, uvula, pillars visible Class II: soft palate, fauces and uvula visible Class III: soft palate, base of uvula visible Class IV: soft palate not visible ET Tube Confirmation: ∼ Confirm with 5 methods as per procedure Capnometry Reference: ∼ EtCO2 readings consistently > 0 indicate tube is not in the esophagus. Verify tbe placement is not right mainstem. In the cardiac arrest, through quality CPR and controlled ventilation attempt to maintain EtCO2 levels as close to 35 – 45 mmHg as possible. Values under 15 mmHg indicate poor survivability. Unsuccessful: 0 mmHg Secondary Interventions:  Dysrhythmia treatment per specific Pediatric Protocol  Vascular Access - Fluid Bolus - Repeat as needed unless pulmonary edema develops  All other injuries should be treated en-route to the hospital if feasible Consult:  RSI Pediatric patients Are Not candidates for Trauma Termination Critical Points:  Any changes in patient condition, refer to appropriate protocol Revision Date 11/25/2008 332 PROCEDURES This Page Intentionally Left Blank Montgomery County Hospital District-EMS 12 LEAD ECG MONITORING Clinical Guidelines – Procedures PROC 01 Page 335 TOC General: Prehospital 12–lead electrocardiograms (ECG) benefit patient care by alerting receiving physicians to potential fibrinolytic candidates, by decreasing the time to inhospital fibrinolytic administration, and by providing a baseline ECG for comparison. Indications: Patients presenting with:  Chest pain or pressure of presumed cardiac etiology, and/or  Shortness of breath of presumed cardiac etiology Contraindications:  Unstable patients  Patients who have been subjected to trauma (relative) Precautions:  Obtaining a baseline 12-Lead ECG is preferred before treatment is initiated. However, Do Not significantly delay treatment and/or transport to conduct test.  When placing electrodes on female patients, always place leads V3 – V6 under the breast rather than on the breast.  Never use the nipples as reference points for electrode location as nipple locations may vary widely. Procedure: 1. Whenever possible, attempt to obtain 12-Lead with patient in supine position. 2. If patient does not tolerate, place in semi-reclining or sitting position. 3. Input patient name, sex, and age. Leave ECG size preset at x 1. (Do Not compromise patient care to input this information). 4. Prep the skin and shave hair as necessary. 5. Apply electrodes as follows and attach the appropriate lead to each electrode: Limb Leads: Extremities (RA) (RL) (LA) (LL) Right arm Right leg Left arm Left leg Precordial Leads: Chest V1– Fourth intercostal space to the right of the sternum V2 – Fourth intercostal space to the left of the sternum V3 – Directly between leads V2 and V4 V4 – Fifth intercostal space at midclavicular line V5 – Level with V4 at left anterior axillary line V6 – Level with V5 at left midaxillary line 6. Secure the cable with the cable clasp to an item of the patient’s clothing. 7. Attempt to obtain the 12-Lead while the vehicle is not moving. 8. Ask the patient to remain motionless for 20 seconds. Revision Date 11/01/2005 335 Montgomery County Hospital District-EMS 12 LEAD ECG MONITORING Clinical Guidelines – Procedures PROC 01 Page 336 TOC 9. Acquire and print two copies of the 12-Lead ECG report. 10. If the monitor detects signal noise (e.g., patient motion or a disconnected electrode), the 12-Lead acquisition is interrupted until noise is removed. Take appropriate action as required (e.g., reconnecting leads). 11. Attach a copy to ECG Strip Form and submit with your patient run report. 12. Remember to include the incident # and/or patient name on the ECG strip. Considerations: Chest Lead Positioning: • Locating the V1 position (fourth intercostal space) is critically important because it is the reference point for locating the placement of remaining V leads. To locate the V1 position:  Place your finger at the notch in the top of the sternum.  Move your finger slowly downward about 1.5 inches until you feel a slight horizontal ridge or elevation. This is the "angle of Louis" where the manubrium joins the body of the sternum.  Locate the second intercostal space on the right side, lateral to and just below the angle of Louis.  Move your finger down two more intercostal spaces to the fourth intercostal space, which is the V1 position. Right Sided 12-Leads:  When a 12-Lead is obtained with ST and T wave changes that are highly suggestive of Inferior wall involvement, move Chest Leads V-3, V-4, V-5, V-6 to the exact location of the R side of the patients chest.  When documenting on the ECG strip add “R side” to each lead that was moved. Revision Date 11/01/2005 336 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures ADENOSINE ADMINISTRATION PROC 02 Page 337 TOC Indication:  SVT  Undifferentiated tachycardia as specified in the SDO. Contraindication:  Sick-sinus syndrome (except in the presence of a functioning artificial pacemaker).  Second or third degree heart block Equipment:  A total of 30 mg of Adenosine for an adult patient or 15 mg for a pediatric patient  2 – 3 ml syringes  2 – 5 ml (or 10 ml) syringes  3 – 10 ml syringes  ECG monitoring.  18 ga syringe needle  10 ml sterile NS  Oxygen  IV start Kit  IV catheters –16 ga -18 ga or use largest bore possible  Tape or securing device Procedure: 1. Verify cardiac rhythm and patient status indicating adenosine administration. 2. Ensure that patient is on ECG monitor and is receiving O2. 3. Establish two IV's (see appropriate procedures): • Saline lock, no more distal than the antecubital fossa • NS infusion TKO 4. Draw up 12 mg of Adenosine in 3 ml syringe or 1 – 12 mg pre-filled syringe. 5. Draw up 10 ml NS in another syringe in 10 ml syringe. 6. Instruct patient that they feel a short period of chest heaviness, chest pain, SOB, etc. 7. Prepare injection lock with alcohol or Chlorohexidine. 8. Begin continuous recording of ECG. 9. Rapidly push the Adenosine through saline lock. 10. Immediately flush with 10 ml of NS (Should be placed in same port as the Adenosine) 11. If no conversion in exactly two minutes, repeat steps #4–10 once. 12. If the patient becomes hypotensive, support with positioning and a fluid bolus. 13. Record ECG for entire medication administration sequence. 14. Re-evaluate vital signs and patient status after Adenosine administration. Revision Date 03/28/2011 337 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures BASIC AIRWAY MANAGEMENT PROC 03 Page 338 TOC General: Conscious patients with a patent airway should be placed in position of comfort consistent with their illness or injury. Patients with compromised airway should be managed in a manner consistent with their illness or injury. Procedure for Establishing and Maintaining an Airway: 1. Open patient’s airway using the appropriate technique for the patient’s condition.  Medical patient: Head tilt-Chin lift or Head tilt-Jaw thrust  Trauma patient: Modified Jaw thrust (jaw thrust with neutral neck alignment) 2. The patient’s airway should be maintained and secured using the appropriate airway device  Oropharyngeal Airways should be used in unconscious patients or patients without a gag reflex.  Nasopharyngeal Airways are better tolerated in conscious patients or in the presence of gag reflex. − Do not use in small infants. Bleeding may occur in children with large adenoids. − Do not force. Always use lubricant.  If necessary refer to individual advanced airway procedures. Procedure for Suctioning the Airway: 1. Turn patient to side if possible, maintaining spinal immobilization in trauma patient. 2. Suction the oropharynx with a large bore rigid or flexible catheter. 3. Suction the lower airway with a flexible catheter down the ET tube and utilize a sterile technique. 4. Limit to 10 – 15 sec. at a time. Suctioning may cause bradycardia. 5. Hyperventilate patient prior to and in between procedure if possible. Procedure for Airway Obstruction: The following techniques for management of obstructed airway apply to adults as well as children and infants with the following exceptions in infants:   Five back blows followed by five chest thrusts are to be used - No Abdominal thrusts. Finger sweep should only occur if foreign body is visualized. Blind finger sweeps are NOT performed in infants. Complete Airway Obstruction: 1. Reposition the airway (jaw thrust or head-tilt/chin-lift). 2. Foreign body maneuvers as indicated.  Infant: 5 back blows, 5 chest thrusts.  Child / Adult: 5 Abdominal thrusts (supine position)  If the patient is still conscious perform the heimlich maneuver Revision Date 11/01/2005 338 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures BASIC AIRWAY MANAGEMENT PROC 03 Page 339 TOC 3. In the event abdominal thrusts are unsuccessful at removing the obstruction and the patient’s airway remains completely obstructed.  Insert a laryngoscope gently into oropharynx to visualize any foreign body.  If a foreign body can be visualized, magill forceps may be used to assist in removal of the foreign body. 4. If the obstruction is not relieved:  Proceed to needle cricothyroidotomy as outlined in the appropriate procedure. 5. When the obstruction is relieved:  Apply high flow oxygen per airway/oxygenation procedure.  Assess the adequacy of ventilations and support as needed.  Consider intubation if appropriate.  Suction aggressively. Vomiting and aspiration commonly occur after relief of an airway obstruction. Be prepared to quickly and aggressively suction the patient. Partial Airway Obstruction: 1. Have patient assume a position of comfort, unless risk of spinal injury, then immobilization is indicated. 2. Apply high flow O2 at 10 to 15 lpm by a non-rebreather mask. 3. Suction upper airway secretions as appropriate. 4. As long as the patient is moving air or coughing, no attempts should be made to relieve a partial airway obstruction. 5. Abdominal thrusts will not be effective and may be injurious to the patient who is still moving air. 6. If patient demonstrates evidence of deterioration (change in mental status, inability to ventilate), treat as complete airway obstruction. Pediatric Considerations Anatomic and Physiologic Features Unique to Children: 1. Large tongues which may occlude the airway and are difficult to sweep away during intubation. 2. Small airway diameter. Minimal edema and swelling may obstruct the airway. 3. Short trachea that predisposes for extubation during transport or head extension. 4. Anterior larynx which often makes intubation difficult. Cricoid pressure should aid in visualization. 5. Infants have large heads that cause a sniffing position. These patients may require a towel roll under their backs to correct the airway position. 6. The epiglottis is soft and “U” or omega shaped. 7. The smallest diameter of the airway is at the cricoid ring, below the cords. This is why uncuffed ET tubes are used in small children. 8. The pediatric airway approaches the size of an adult airway at age 8 or 9 years of age. 9. Infants are obligate nose breathers until 2 – 6 months of age. 10. The diaphragm is the main muscle used for breathing in infants due to the undeveloped intercostal muscles. This may cause inflated stomachs secondary to crying. Revision Date 11/01/2005 339 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures BLOOD DRAW REQUEST BY TEXAS J.P. PROC 04 Page 340 TOC General:  Per HB 3775 of the State of Texas, a Justice of the Peace in the State of Texas can order a paramedic to draw blood for the purpose of determining the alcohol content or the presence of chemical substances. This bill became effective 09/01/99.  A certified paramedic acting at the request of a Justice of the Peace shall not incur any civil or criminal liability as a result of the blood draw.  If, for any reason, an MCHD paramedic feels uncomfortable performing this procedure, he/she should contact a Supervisor immediately. If a Supervisor is unavailable, ask Alarm to contact one of the following individuals via the 688 paging system: - Assistant Director EMS-Operations - Assistant Director EMS-Clinical - EMS Director - Any off-duty Supervisor immediately available Procedure: 1. Blood draw should be under the supervision of the requesting Justice of the Peace. 2. Use the blood draw kit as supplied by the Justice of the Peace. 3. Don appropriate personal protective equipment. 4. Cleanse the venipuncture site using alcohol preps or Chlorohexidine. 5. Make venipuncture with an 18 or 20 ga catheter. 6. Withdraw blood into two (2) gray top tubes using the needleless vacutainer equipment. 7. Slowly invert the tubes at least 5 times to assure proper mixing of the blood and the anticoagulant powder. The paramedic should write his initials, date and time on the tube before handing the tubes to the Justice of the Peace. 8. Discontinue the I. V. unless otherwise indicated. 9. The paramedic who drew the blood sample should sign any required forms or labels and observe the blood tubes being sealed by the officer. 10. If not already done, an incident number should be generated from the alarm office. 11. Accurate and thorough documentation of the circumstances and events should be recorded including name of JP and Peace Officer requesting procedure, site of the blood draw, time performed and time the blood sample was released to the Peace Officer. 12. Have the Officer or other authorized individual sign as having received the blood sample to document chain of custody after being drawn by EMS. This documentation is important so that the integrity of the blood draw by MCHD-EMS is not in question. Revision Date 03/28/2011 340 Montgomery County Hospital District-EMS BLOOD GLUCOSE ANALYSIS Clinical Guidelines – Procedures PROC 05 Page 341 TOC General: Treat patient per appropriate Treatment SDO. See the Adult Medical and Pediatric Hypoglycemia and Hyperglycemia SDO's. Indications: Patients with a known history of hypoglycemia or diabetes mellitus. Any patient presenting with altered mental status or other signs/symptoms of hypo/hyperglycemia, including:      Tremors Weakness Nausea Abdominal Pain Unconscious/unresponsive Procedure: 1. Gather and prepare equipment. 2. Don appropriate protective gear. 3. Wipe pad of finger with alcohol prep. 4. Stick finger with the lancet device and press finger to form a small drop of blood. - Blood samples can be obtained from site used to establish an intravenous access, or from a separate venipuncture site. 5. Touch and hold the Test End (tip) of the Test Strip to the drop of blood until after the meter "beeps." 6. Blood will automatically be drawn into the Test Strip and the timer will begin down from "60" seconds. 7. After "60" seconds the blood glucose result will appear in the display window. 8. Document the glucometer reading and treat the patient as indicated by the analysis and protocol. - If "Hi" appears your BG level may be above 600 mg/dI. - If "Lo" appears in the display, your BG level may be below 20 mg/dI. 9. Repeat glucose analysis as indicated for reassessment after treatment and as per protocol. 10. Dispose of the used Glucolet device in the sharps container. Remove the Test Strip from the Glucometer and dispose in biohazard bag. Considerations:  It is imperative that the Glucometer is calibrated correctly with the appropriate control code.  In the event that the control code is different from the regent strip code a false reading may be displayed. Revision Date 06/21/2012 341 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures CHEST DECOMPRESSION PROC 06 Page 342 TOC General: Tension Pneumothorax is a life threatening condition. Decompressing the chest is considered potentially lifesaving and may be performed on any patient: 1. found in cardiac arrest, or 2. with chest, abdominal, or multi-system trauma AND signs of hemodynamic instability (Hypotension and/or falling systolic blood pressure, Narrowing pulse pressure), AND one or more of the following indications. Indications:  Increased respiratory difficulty / increased difficulty in bagging  Sudden decrease in level of consciousness  Loss of peripheral pulses  Pale and/or cyanotic with diaphoretic skin  Diminished or Absent unilateral breath sounds  Distended neck veins  Tracheal deviation (often a late sign)  Pulseless electrical activity  Subcutaneous Emphysema Equipment:  Longest available10, 12, 14 or 16 ga over-the- needle catheter(s)  10 ml syringe  Skin cleanser  Dressing and tape  Stethoscope  ECG monitoring supplies and equipment  Oxygen  Appropriate ventilation equipment Precautions:  Crepitus and/or subcutaneous air may be present with a tension pneumothorax.  Always insert needle over (cephalic to) the rib to avoid neurovascular bundle. Complications:  Creation of a Pneumothorax if not already present  Laceration of blood vessels and/or nerves  Injury to lung or thoracoabdominal organs  Infection from secondary to procedure Revision Date 06/21/2012 342 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures CHEST DECOMPRESSION PROC 06 Page 343 TOC Procedure: 1. Don appropriate personal protective gear including eyewear, mask, and gloves. 2. Evaluate and maintain the airway, provide oxygenation and support ventilations. 3. Assemble and prepare equipment. 4. Attach needle to 10 mL syringe  In adults, use a largest available needle gauge  In children < 12 years, use a 14 ga needle. ON THE AFFECTED SIDE: 5. Identify intercostal space at mid-clavicular line, between the 2nd and 3rd ribs (If not possible, the fifth intercostal space at mid-axillary line may be used). 6. Swab with skin prep at midclavicular line. 7. Position tip of needle just over top of the 3rd rib at the midclavicular line. Insert needle into the chest at 45° angle to the chest wall and parallel to sternum. At the pleural cavity a slight "give" is felt. Advance further into chest until bevel of needle clears the pleura. 8. If decompression occurs a rush of air may be heard. 9. Advance the catheter over the needle and then remove needle. 10. Secure catheter to chest. SPECIAL NOTES:  Individuals who have chronic COPD may have a spontaneous pneumothorax that progresses to a tension pneumothorax.  A tension pneumothorax may be precipitated by the occlusion of an open chest wound dressing.  Rush of air and/or patient improvement indicates correct placement.  If the patient has sustained multi-system trauma, bilateral decompression may be required.  Once catheter is placed, Prehospital personnel should not remove it. If the needle has been improperly placed, tape the catheter to the patient’s chest and repeat the procedure.  Remember to go just above the rib due to all of the major structures (arteries, veins, and nerves) which lie below the rib. The closer you stay to the top of the rib, the less chance of complication Revision Date 06/21/2012 343 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures COMBITUBE PROC 07 Page 344 TOC Indications:  In an apneic patient when endotracheal intubation is unsuccessful  Patient ≥ 5 feet tall  Patient should be unconscious Contraindications:  Responsive patients with an intact gag reflex.  Patients with known esophageal disease.  Patient who have ingested caustic substances.  Patients under 5 feet tall. Complications:  Blue pilot is inflated but air is heard leaking from mouth. Insert up to 20 ml  of additional air in #1 blue pilot.  Both pilots are inflated but chest does not rise and no air is heard when ventilating in either tube. Deflate cuffs and withdraw airway 1 – 2 cm; re-inflate cuffs and repeat steps as listed in the procedure.  Pilot bulbs do not remain inflated. Remove airway. Equipment:  Combitube  KY Jelly or other water soluble lubricant  Securing device  Syringe 20 ml  Syringe 100 ml  Suction apparatus  Bag valve mask with oxygen source  Bulb device  End-tidal CO2 detector, or other approved device Procedure: 1. Personal protective equipment including gloves, eye protection and mask. 2. Prepare, position, and oxygenate patient. 3. Provide suction as necessary. 4. Test cuffs by inflating 100 ml and 15 ml of air into the cuffs of the Combitube. The cuffs are labeled with the correct amount of air for each cuff. 5. Hyperoxygenate for 30 seconds prior to insertion. 6. Assure c-spine stabilization if necessary. 7. Place patient’s head in a neutral position. 8. Lubricate ET tube generously with water-soluble lubricant. 9. Perform tongue-jaw lift. Revision Date 06/21/2012 344 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures COMBITUBE PROC 07 Page 345 TOC 10. Insert Combitube until the teeth are aligned between the two black lines. Avoid cuff contact with teeth. Limit placement attempt to 30 seconds. 11. Inflate proximal cuff (blue pilot). 12. Inflate distal cuff (white pilot). 13. Ventilate through blue #1 tube. Listen for epigastric and lung sounds. Watch for chest rise. Utilize bulb check and EtCO2 detector to confirm tube placement. 14. If no chest rise is noted, inappropriate air sounds are heard, or bulb check remains deflated, ventilate through clear #2 tube and confirm tube placement with EtCO2 detector. 15. Gastric suctioning may be done by inserting a French suction catheter into #2 tube while continuing to ventilate through #1 blue tube. 16. Gastric suctioning is not possible through #1 blue tube. Revision Date 06/21/2012 345 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) PROC 08 Page 346 TOC Pre-CPAP Patient Assessment  Assess patient, record vital signs and pulse oximetry at room air  Apply Capno-Mask to evaluate Capnography waveform  Administer O2 by non-rebreather mask while preparing equipment Indications for Use  Adult patient able to fit mask with proper seal  Systolic BP > 90  GCS > 10  Significant respiratory distress that is not responsive to conventional therapy  AND two or more of the following:  SpO2 < 92%  Respiratory Rate > 25/minute  Use of Accessory muscles or retractions Contraindications for Use  Inability to maintain open airway  Respiratory Arrest/apnea  Inadequate respiratory effort  Suspected pneumothorax or chest trauma  Excessive secretions  Tracheostomy  Patients at risk for aspiration (nausea/vomiting, foreign body airway obstruction, etc.)  Facial trauma that would interfere with proper fit of mask CPAP Procedure (CPAP) 1. 2. 3. 4. Place the patient in a seated position with legs dependant (if possible) Monitor ECG and vital signs --B/P, heart rate, Respiratory rate, SpO2 Verify that the CPAP Adjustment Knob is turned all the way to the left (off) Attach CPAP unit to an Oxygen source a. Ensure the tank valve is fully open b. Verify that the liter flow to Oxygen barb is set to zero 5. Connect Locking Bayonet Outlet Adapter to CPAP unit a. Both bayonet tabs should disappear once adapter is turned clockwise 6. Size Mask for patient (Medium will accommodate most patients) 7. Attach Mask to Exhalation Valve 8. Attach head strap to one side of the Face Mask 9. Inform patient of procedure 10. Open Adjustment Knob slowly to begin a slight flow of oxygen 11. Gently apply Face Mask to the patient a. Instruct patient to breath in through their nose slowly and exhale through their mouth as long as possible (count slowly and aloud to four (4) then instruct to inhale slowly) Revision Date 08/01/2007 346 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP) PROC 08 Page 347 TOC 12. Completely attach the head strap to the other side of the CPAP Mask a. Ensure a tight seal and adjust as necessary b. Explain to the patient that you will begin to slowly increase the pressure and to continue exhaling out against the pressure as long as possible before inhaling 13. Increase CPAP by turning the Adjustment Knob to the right 14. Increase CPAP to achieve an initial CPAP of 3 cmH2O 15. Once the patient is compliant with the procedure, slowly increase CPAP to 10 cmH2O if needed. Tirate to effect. Critical points and Special Notes  Success is highly dependent upon patient tolerance, and EMT-P ability to coach  Instruct patient to breath in through nose and exhale through mouth as long as possible  Deterioration on CPAP ⇒ mechanical ventilation/intubation  Significant respiratory distress that is not responsive to conventional therapy  Deterioriation of mental status  Increase of the EtCO2  Decline of SpO2  Progressive fatigue  Monitor closely for development of pneumothorax and or hypotension  Patients should be closely monitored with SpO2, EKG, BP, ETCO2  Monitor patients closely for vomiting and or gastric distention  Inline nebulization may be utilized with CPAP in place Revision Date 08/01/2007 347 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures C-SPINE CLEARANCE PROC 09 Page 348 TOC Indication for C-Spine Clearance in Pre-hospital Setting All patients that are candidates for pre-hospital C-Spine clearance by MCHD-EMS personnel SHOULD have a Negative (no) response to ALL of the following: 1. 2. 3. 4. 5. 6. Patient < 6 years of age Altered mental status and/or decreased level of consciousness Suspected alcohol intoxication and/or drug abuse Presence of neurological deficit or complaint Presence of C-Spine pain and/or point tenderness Distracting injuries of any kind. (e.g., long bone fractures, abdominal pain, chest pain, crushing injuries, extensive BSA burns, etc.) 7. Language barrier between Paramedic and patient 8. Strong evidence of potential spinal injury based on mechanism of injury (e.g., high-speed rollover MVC, diving accident, fall >20 feet, etc.) 9. Voluntary range of motion with pain Any patient with a Positive (yes) response to ANY ONE of the above items SHOULD receive C- Spine Restriction prior to transport by MCHD-EMS personnel. Note: If at anytime the paramedic feels uncomfortable clearing the c-spine, the patient should be fully immobilized. Revision Date 11/01/2005 348 Montgomery County Hospital District-EMS END TIDAL CO2 DETECTION Clinical Guidelines – Procedures PROC 10 Page 349 TOC General: Capnometry involves the continuous measurement of carbon dioxide concentrations (CO2) in respiratory gases of mechanically ventilated patients. Capnometry reflects CO2 elimination. Indications: Indicated to verify and maintain tracheal intubation. Procedure:  Endotracheally intubate the patient  Attach End-Tidal CO2 detector to endotracheal tube.  Note color change on each respiratory failure or cardiac arrest patient.   - More Purple: Less CO2 - More Yellow: More CO2 The CO2 detector shall remain in place with the airway and monitored throughout the prehospital care and transport. Tube placement should be verified frequently and always with each patient move or loss of color change in the End-Tidal CO2 detector. Contraindications: There are no absolute contraindications to capnometry in mechanically ventilated patients if the data obtained is evaluated in conjunction with other diagnostic test and the patients overall clinical condition. Considerations:  It is important to note that although the capnometry provides valuable information about correct tube placement and the efficiency of ventilation, it is not a replacement or a substitute for a complete respiratory assessment.  Low or absent cardiac output may negate its use for placement verification.  Certain situations may affect the reliability of the capnometer. The extent to which the reliability is affected varies somewhat among types of devices.  The infrared spectrum of CO2 has some similarities to the spectra for both oxygen and nitrous oxide. High concentrations of either or both oxygen or nitrous oxide may affect the capnometer results. Other gases which could cause false readings: Helium and Freon. Note: Contamination of the monitor by secretions or condensate, a sample tube of excessive length, a sampling rate that is too high, obstruction or decreased perfusion of the sampling chamber may lead to unreliable results. Revision Date 11/01/2005 349 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures INTUBATION PROC 11 Page 350 TOC INTUBATION – OROTRACHEAL Indications: Any patient unable to maintain the patency of their airway, requiring mechanical ventilation and/or PEEP Patients with possible increasing ICP. Contraindications: Presence of gag reflex (consider other appropriate methods of airway management or RSI) Equipment:  ET introducer device  Endotracheal tube(s) of appropriate size  Stylet for ET tubes  Laryngoscope handle and batteries  Laryngoscope blades of the appropriate sizes and desired type  Bag valve mask, complete  KY Jelly or other lubricant  Securing device  Syringe 10 ml  Suction apparatus  Stethoscope  Bulb Check (if >20 kg or 5 years of age)  End-tidal CO2 detector, or other approved device  Oxygen Procedure: 1. Don personal protective equipment (gloves, eye protection, etc.). 2. Manually establish or secure the airway and oxygenate the patient. 3. Chose proper ET tube and prepare for insertion without stylet. 4. Prepare ET introducer device for insertion by curving the bougie and ensuring the distal tip is angulated. 5. Position patient’s head as appropriate (neutral if c-spine injury suspected, otherwise “sniffing” position). See “Making Best Attempt.” 6. Remove mask and oral airway. 7. Perform laryngoscopy, obtaining the best possible view of the glottic opening. Insert laryngoscope blade, moving tongue to the left and lifting epiglottis. 8. Advance the bougie, continually observing its distal tip, with the concavity facing anteriorly. 9. Visualize the tip of the bougie passing posteriorly to the epiglottis where possible, and anterior to the arytenoid cartilages. 10. As the tip of the bougie enters the glottic opening you should either feel ‘clicks’ as it passes over the tracheal rings or the tip will arrest against the wall of the airway Revision Date 07/26/2010 350 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures INTUBATION PROC 11 Page 351 TOC (hold-up). This is a good indicator of correct insertion, but is not 100% accurate. Failure to elicit clicks or hold-up is indicative of esophageal placement. If hold-up is felt, the bougie should be withdrawn approximately 5cm to avoid the ET tube impacting against the carina. 11. Pass the ET tube over the proximal end of the bougie and through the glottic opening, limiting movement of the bougie as much as possible. Advance tube until cuff is just past the cords. STOP advancing. 12. Hold the ET tube securely in place and remove the bougie. 13. ET tube placement should be verified by at least five methods 14. Confirm placement with a Bulb Detector. (> 20 kg or 5 years of age). 15. Check for presence of breath sounds in left and right chest, and absence of breath sounds in abdomen. 16. Check for rise and fall of patients chest 17. Check for increased SpO2 18. If you are unsure of placement, remove tube and hyperventilate patient with bag-valve mask. 19. Once proper placement verified inflate cuff with 5 to 10 ml of air and insert oropharyngeal airway or other bite block. 20. Secure the tube to the patient's head. 21. Apply end-tidal CO2 detector and continuously monitor expired CO2. (most effective method to verify tube placement and should be done whenever possible by either end-tidal CO2 detector or if malfunctioning use a colorimetric device) 22. Reassess airway and breath sounds each time after moving the patient. 23. Consider placing a NG tube to clear stomach contents after the airway is secured with an ET tube. 24. Consider motion restriction of patient’s head with a c-collar or other device to maintain tube position. RECONFIRM tube placement often, ESPECIALLY AFTER moving patient or manipulating ET tube. Revision Date 07/26/2010 351 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures INTUBATION PROC 11 Page 352 TOC INTUBATION – NASOTRACHAEL Indications:  Comatose patients with spontaneous respirations  Conscious patient with severe hypoxia  Oral cavity not sufficiently accessible to permit orotracheal intubation  Wired jaws  Trismus  Active seizing Contraindications:  Apneic patient  Facial trauma (blunt or penetrating)  Penetrating neck wounds  Nasal or Nasopharyngeal obstruction from deviated septum  Basilar skull fracture  Hypertension  Suspected CVA Complications:  Nasal Bleeding  Tube malposition in the: - Vallecula - Pyriform fossa - Esophagus  Laryngospasm  Retropharygeal laceration Equipment:  Endotracheal tube  KY Jelly or other water soluble lubricant  Securing device  Syringe 10 ml  Suction apparatus  Bag valve mask with oxygen source  Bulb device  End-tidal CO2 detector, or other approved device Procedure: 1. Personal protective equipment including gloves, eye protection and mask. 2. Prepare, position, and oxygenate patient. 3. Chose proper ET tube about 1 mm less than for oral intubation. 4. Lubricate ET tube generously with water-soluble lubricant. Revision Date 07/26/2010 352 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures INTUBATION PROC 11 Page 353 TOC 5. Pass the tube in the largest nostril with the beveled edge against the nasal septum and perpendicular to the facial plate. 6. Use forward and lateral back and forth rotational motion to advance the tube. Never force the tube. 7. Pause at the level of the pharynx so gag is minimal and breath sounds are audible through the tube. 8. Apply firm, gentle cricoid pressure and advance the tube quickly past the vocal cords during inspiration. 9. Confirm placement with a Bulb device. 10. Check for presence of breath sounds in left and right chest, and absence of breath sounds in abdomen. 11. If you are unsure of placement, remove tube and hyperventilate patient with bag-valve mask. 12. Once proper placement is verified inflate cuff with 5 to 10 ml of air. 13. Secure the tube to the patient's head. 14. Apply end tidal carbon dioxide detector and monitor expired CO2. 15. Reassess airway and breath sounds after movement. 16. Consider immobilization of patient’s head to maintain tube position with c-collar or other immobilization device. If able, consider placing an NG tube to clear stomach contents after the airway is secured with an ET tube. Transport should not be delayed to place an NG tube. Considerations:  If the patient is conscious, he or she should receive step by step instructions before and during the procedure.  Patient should be positioned either in sitting position or supine to align the mouth, pharynx and the larynx.  This is done by placing the patient in sniffing position, and by placing a folded towel at the base of the patient’s neck.  However, if the cervical spine injury is suspected, the head and neck should be maintained in neutral position. Revision Date 07/26/2010 353 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures INTUBATION PROC 11 Page 354 TOC INTUBATION – DIGITAL Indication: Unable to orally or nasally intubate Contraindications: Conscious and responsive patient Patient with intact gag or clenched jaw Equipment:  Endotracheal tube  KY Jelly or other lubricant  Securing device  Syringe 10 ml  Suction apparatus  Bag valve mask with oxygen source  Bulb device  End-tidal CO2 detector, or other approved device Procedure: 1. Prepare equipment including suction. 2. Ensure patient is well oxygenated by hyperventilation. 3. Don personal protective equipment. 4. Maintain trauma patient in neutral position with manual stabilization throughout procedure. 5. Insert index and middle finger to palpate and elevate epiglottis. 6. Pass distal end of the ET tube between index and middle finger and advance tube. 7. Confirm placement with a Bulb device. 8. Check for presence of breath sounds in left and right chest, and absence of breath sounds in abdomen. 9. If you are unsure of placement, remove tube and hyperventilate patient with bag-valve mask. 10. Once proper placement verified inflate cuff with 5 to10 ml of air and insert oropharyngeal airway or other bite block. 11. Secure the tube to the patient's head. 12. Apply end tidal carbon dioxide detector and monitor expired CO2. 13. Reassess airway and breath sounds after movement. 14. Consider placing a NG tube to clear stomach contents after the airway is secured with an ET tube. DO NOT delay transport to accomplish placement of NG tube. 15. Consider immobilization of patient’s head with c-collar or other device to maintain tube position. Revision Date 07/26/2010 354 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures INTUBATION PROC 11 Page 355 TOC INTUBATION – STOMAL Indications: Pre-existing tracheotomy With any of the following: - Respiratory Arrest - Hypoventilation Contraindications: None when used in the emergency setting Equipment:  Endotracheal tube  KY Jelly or other lubricant  Securing device  Syringe 10 ml  Suction apparatus  Bag valve mask with oxygen source  Bulb Check  Stethoscope  End-tidal CO2 detector, or other approved device Procedure: 1. Assemble the equipment while continuing ventilation with BVM. 2. Chose the tube size. (Note: if the stoma is constricted you may need to use a smaller size tube; 6mm or 7mm) 3. Position patient. 4. Insert the tube through the stoma. 5. Advance the tube until the cuff is just inside the stoma. Insert air into the cuff to prevent an air leak. 6. Confirm placement with a Bulb device. 7. Check for presence of breath sounds in left and right chest, and absence of breath sounds in abdomen. If you are unsure of placement, remove tube and hyperventilate patient with BVM device and supplemental oxygen. 8. Once proper placement has been verified inflate cuff with 5 to 10 ml of air. 9. Secure the tube to the patient's neck and head. 10. Apply end-tidal CO2 detector and monitor expired CO2. 11. Reassess airway and breath sounds each time after moving the patient. 12. Consider placing a NG tube to clear stomach contents after the airway is secured with an ET tube. The ET tube DOES NOT need to be modified in any way. Revision Date 07/26/2010 355 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures EXTERNAL PACING PROC 12 Page 356 TOC Assessment Requirements:    ABC’s Pulse oximetry ECG monitoring Demand Pace Mode (Requires ECG leads and pads)          Turn the Therapy Knob to Pacer. Press the Lead Select button to select the desired lead (Lead II) Verify white R-wave markers appear above or on the ECG waveform. Press the Pacer Rate soft key, select the desired number of paced pulses per minute (60 ppm), and press the Menu Select button. If needed, press the Pacer Output soft key, use the Navigation buttons to adjust the initial pacer output, and press the Menu Select button. Press the Start Pacing soft key. Verify white pacing markers appear in front of every paced QRS. If cardiac capture is not obtained , press the Pacer Output soft key, increase the output until capture occurs, then decrease the output to the lowest level that still maintains capture, and press the Menu Select button. Verify the presence of a peripheral pulse. Fixed Mode Pacing (Can be done with pads only). Must have the 3-lead attached to the patient to see ECG waveforms.           Turn the Therapy Knob to Pacer. Set the pacer mode to Fixed. Select Pacer Mode from the Main Menu. Select Fixed and press the Menu Select button. If using leads, press the Lead Select button to select the desired lead (Lead II). Press the Pacer Rate soft key, use the navigation buttons to adjust the initial pacer output (60 ppm), and press the Menu Select button. If needed, press the Pacer Output soft key, use the Navigation buttons to adjust the initial pacer out, and press the Menu Select button. Press the Start Pacing soft key. Verify cardiac capture. If it is not obtained, press the Pacer Output soft key, increase the output until capture occurs, decrease the output to the lowest level that still maintains capture, and press the Menu Select button. Verify the presence of a peripheral pulse. Note: In Fixed and Demand modes, if monitoring SpO2 when pacing, activate the Pulse alarms to assess for peripheral perfusion through the SpO2 transducer. Revision Date 02/28/2011 356 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures HELMET REMOVAL PROC 13 Page 357 TOC General: In the event that an individual is injured while wearing a protective helmet, the primary assessment should proceed as always with concern for assessing airway, breathing and circulation while addressing the potential for cervical spine injury.  The goal is to appropriately treat the patient in terms of cervical spine immobilization and manage the patient's airway. Procedure: The decision whether to remove a helmet or not to remove a helmet should be based on the following criteria: Tight-Fitting Helmets: 1. If the patient is awake and able to protect his/her airway, it is generally preferable to leave the helmet in place using the helmet to assist with immobilization. 2. If the airway cannot be controlled for any reason with the helmet in place, the helmet should immediately be removed while maintaining in-line immobilization. 3. If the patient has an altered level of consciousness and/or is unable to protect his/her airway. The face shield should be immediately removed to allow access to the airway. If the face shield cannot easily be removed, the helmet should be removed while maintaining in-line immobilization. Loose-Fitting Helmets: 1. If the patient is wearing a loose helmet that does not conform closely to his/her head, the helmet should be removed using in-line immobilization prior to completing spinal immobilization on the patient. 2. The void behind the Occiput created by the helmet and any other protective sports equipment should be filled during the spinal immobilization procedure Considerations:  When immobilizing patients with the helmet in place, the backboard portion of most immobilization devices may cause the neck to flex forward when the patient's head is placed on it. For that reason, head immobilization devices should generally not be used in these patients. The helmet should rest directly on the backboard with towel rolls used to provide lateral support to the helmet.  EMS crews should work closely with team trainers and physicians for organized team sports. When providing scheduled standbys at sporting events, EMS personnel should introduce themselves to the sports medicine personnel of the teams prior to the game. Revision Date 11/01/2005 357 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures MEDICATION ADMINISTRATION PROC 14 Page 358 TOC CONTINUOUS INTRAVENOUS MEDICATION INFUSION General: Any medication that should be administered via IV infusion as indicated by manufacturer and/or protocol. Equipment:  All equipment as noted for intravenous access.  Medication and IV fluid for infusion (as specified in protocol or Drug Reference).  18 g syringe needle or needleless adapter.  60 gtts/ml IV drip chamber and tubing. Procedure: Continuous Drip 1. Explain the procedure to the patient and inquire for medication allergies. 2. Don appropriate personal protective equipment. 3. Pre-mixed intravenous medications are selected or appropriate dose of medication is added to intravenous fluid bag. Affix label to fluid container. Shake bag to distribute medication. 4. Attach 60 gtts/ml drip chamber and tubing. Flush air from tubing and attach 18-ga needle to end of tubing. Insert tubing into Baxter pump 5. Insert needle into IV injection port (use port closest to patient). 6. Begin medication infusion. Check for patency (indicated by good flow and absence of infiltration). 7. Once patency is established, set infusion rate on the Baxter pump. 8. Monitor patient and pump during transport for consistency and patency of IV/medication line. Revision Date 11/01/2005 358 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures MEDICATION ADMINISTRATION PROC 14 Page 359 TOC ENDOTRACHAEL MEDICATION ADMINISTRATION General: Critical patient requiring rapid administration of potentially life-saving medications in whom vascular access cannot be established in a timely manner and Endotracheal intubation has been successfully accomplished. Indications for Administration: Administration of ET medications as per SDO. The medications that may be given down the ET tube are:  Lidocaine  Epinephrine  Atropine  Naloxone (Naloxone) Equipment:  All equipment as noted in the Endotracheal Intubation Procedure.  Medications, appropriate syringes, and syringe needles.  If medication not diluted, 10 ml NS for dilution. Procedure: Note: All medications administered via the ET tube are doubled. 1. 2. 3. 4. 5. Endotracheal intubation with confirmation of tube placement. Draw up medication or prepare pre-filled syringe for use. Reconfirm tube placement by auscultation. Hyperventilate patient for 30 seconds. Rapidly inject the medication down the tube in a bolus that is diluted or followed by normal saline to flush the tube. The total fluid that should be administered in one bolus is 10 ml maximum. 6. Hyperventilate the patient for at least 30 seconds following medication administration. Revision Date 11/01/2005 359 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures MEDICATION ADMINISTRATION PROC 14 Page 360 TOC INTRAMUSCULAR MEDICATION ADMINISTRATION PROCEDURE General:  Medications requiring Intramuscular administration. Equipment:  Appropriate size syringe  18 ga syringe needle (to draw up medication)  20 – 22 ga syringe needle (medication administration)  Alcohol preps  Band-Aid Procedure: 1. Explain procedure to patient and inquire about medication allergies. 2. Medication is prepared in syringe of less than 5 ml with needle 18–22 ga, 1 1/2–2 inches. 0.2 ml of air may be added to syringe. 3. Site is selected and cleansed (deltoid, dorsal gluteal, ventro-gluteal). 4. Spread skin taut, insert needle at 90-degree angle, and aspirate. 5. If no blood appears in syringe, inject medication slowly. 6. Withdraw the needle and massage the site with alcohol prep or 4x4. 7. Dispose of syringe in sharps container. 8. Place a Band-Aid over the injection site Revision Date 11/01/2005 360 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures MEDICATION ADMINISTRATION PROC 14 Page 361 TOC INTRAVENOUS MEDICATION ADMINISTRATION General: Any patient requiring medications via the intravenous route. Indications for Administration: *Prior to any pre-hospital medications being administered All of the following should be present: 1. Appropriate patient assessment has determined the need for a medication. 2. Patient is interviewed for known allergies and medication history to identify risk of drug interaction or potentiation. 3. The on-scene In-Charge is familiar with:  Guidelines for administration  Actions  Side-effects  Drug interactions  Contraindications 4. Medication is checked for:  Expiration date  Clarity Equipment:  All equipment and supplies as noted for intravenous access  Syringe(s) of appropriate size(s) for medication dose  18 ga syringe needles or Baxter Interlink system  Alcohol preps Procedure: IV Bolus 1. Establish vascular access. 2. Explain the procedure to the patient and inquire about medication allergies. 3. Don appropriate personal protective equipment. 4. Medication is prepared in syringe with luer-lock connector or protected-needle. (A needle to insert into a port should only be used as a last resort.) 5. All air is cleared from syringe and excess medication expelled. 6. Site is cleansed and syringe is inserted into capped port of IV line. 7. Patency of IV is checked by aspirating blood or by monitoring flow with no signs of infiltration. 8. IV line is clamped or flow is controlled to flush medication, as medication is pushed into IV port. 9. Time taken to administer medication is specific to medication. Flush IV line to assure medication administration. 10. Monitor IV catheter site for signs of infiltration. 11. Dispose of syringe in appropriate container. Revision Date 11/01/2005 361 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures MEDICATION ADMINISTRATION PROC 14 Page 362 TOC NEBULIZED MEDICATION ADMINISTRATION Indicated  Dyspnea with evidence of bronchospasm (wheezes, silence), due to asthma, or COPD.  Patient SHOULD be alert and have adequate respiratory effort to inspire mist. Contraindicated:  Severely obtunded or unconscious patient. Note: Nebulized medications have little therapeutic effect when given to patient with little or no tidal volume. CHF/Pulmonary Edema Note: Patients with suspected Pulmonary Edema may be given Nebulized Albuterol treatments but should not be given Nebulized Atrovent. Equipment:  Medication for Nebulizer  Oxygen-driven nebulizer  Oxygen Procedure: 1. Self-administered by the patient with a metered dose inhaler (MDI), hand-held nebulizer or nebulized with positive-pressure breathing device such as a bag-valvemask or with an in-line device attached to the ET tube. 2. Avoid contamination of equipment. If contamination occurs replace contaminated equipment prior to use. 3. Medication is measured and introduced into nebulizer and 8 –10 liters of oxygen is attached to nebulizer. 4. Informs patient of need for treatment. Inquires about medication allergies. 5. Patient is instructed to breathe normally and to hold a deep inspiration every 4 – 5 breaths. 6. Treatment is continued until all medication is gone or is discontinued due to complication in patient condition. - Ectopy noted on ECG - Heart rate increases by more than 20 bpm Revision Date 03/28/2011 362 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures MEDICATION ADMINISTRATION PROC 14 Page 363 TOC ORAL MEDICATION ADMINISTRATION General: Patient assessment indicates administration of oral medications for optimal patient care and outcome. Oral medications currently administered by MCHD are:  ASA 324 mg  Oral Glucose  Nitroglycerin  Charcoal Equipment:  No special equipment required Procedure: 1. Inquire about medication allergies. 2. Don appropriate personal protective equipment. 3. Prepare medication for administration. Prior to administration check for: - Expiration Date - Name of medication being administered to ensure medication chosen is correct. 4. Obtain permission from patient to administer medication. Advise the patient what to expect after medication has been administered. (e.g., Nitro may cause headache but should relieve chest pain, etc.). 5. Provide medications to patient with direction on the administration (i.e.: to be chewed, swallowed, held under the tongue) Note: Oral medications Should Not be administered to patients with decreased and/or altered levels of consciousness. Revision Date 11/01/2005 363 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures MEDICATION ADMINISTRATION PROC 14 Page 364 TOC RECTAL MEDICATION ADMINISTRATION Indicated: Any patient in status seizures requiring medication administration when an IV cannot be established. Consider administration of IM Midazolam BEFORE rectal administration of Diazepam. Contraindicated:  Respiratory insufficiency  Hypotension Equipment:  A # 6–8 fr suction catheter  Diazepam  2–5 ml syringe  Tape  Lubricant Procedure: 1. Carefully restrain patient manually in knee-chest or supine position. 2. Assure airway patency and administer supplemental Oxygen. 3. Don personal protective equipment. 4. Draw up the calculated dose of Diazepam: 0.4 – 0.6 mg/kg pediatric OR 4 –20 mg adult. 5. Draw up 5 ml NS in the second syringe. 6. Have assistant hold legs apart. 7. Attach a #6–8 fr suction catheter to the end of a syringe that contains medication to be administered. 8. Lubricate the tip of the catheter 9. Gently insert catheter into rectum and instill medication. 10. Flush the suction catheter with 5 ml of NS. 11. Optional-withdraw the catheter. 12. If the catheter is withdrawn tape the buttocks closed. 13. Use manual pressure to facilitate drug retention. 14. Monitor patient for respiratory depression, hypotension or any other change in status. Revision Date 11/01/2005 364 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures MEDICATION ADMINISTRATION PROC 14 Page 365 TOC SUBCUTANEOUS MEDICATION ADMINISTRATION General: Any medication requiring Subcutaneous administration. SQ injections are not recommended for patients with poor perfusion. (Shock) Equipment:  Appropriate size syringe  18 ga syringe needle (to draw up medication)  25 ga syringe needle  Alcohol preps  Band-Aid Procedure: 1. Medication is prepared in syringe of 1 ml or less with needle 25–27 ga 1/2–5/8 “. 2. Explain the procedure to the patient and inquire about medication allergies. 3. A site is selected and cleansed. Use the lateral aspect of the upper arm or leg. 4. Pinch skin up into a fat fold of at least 1”. 5. Insert needle at 45-degree angle. 6. Aspirate the syringe. 7. If no blood appears in syringe, inject medication slowly. 8. Withdraw the needle and gently massage site with alcohol wipe or 4x4. 9. Dispose of syringe in sharps container. Revision Date 11/01/2005 365 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures NASOGASTRIC TUBE INSERTION AND LAVAGE PROC 15 Page 366 TOC Indications: Nasogastric lavage may be performed on conscious or unconscious patients in any of the following situations: 1. Patients who have ingested non-caustic poisons or excessive amounts of medications 2. Cardiac arrest patients for the purpose of alleviating abdominal distention 3. Hyperthermic patients to lower body temperature. Contraindications:  Nasogastric lavage should not be performed if the patient is convulsing  DO NOT delay transport to accomplish this procedure. Procedure: 1. Explain procedure to patient and question the patient regarding any nasal injuries or occlusions. 2. Assemble and prepare equipment. 3. Don appropriate personal protective items including eyewear, mask and gloves. 4. Raise head of bed to high fowler’s position if possible. Support the patient's head and shoulders with a pillow. 5. Select appropriate catheter size: - Adults: 12 – 18 fr. - Pediatric: 8 –12 fr. 6. Measure the tube by placing the tip of the tube on the patient's nose, then extend the tube to the tip of the ear lobe and then to the end of the xyphoid process. Use a piece of tape to mark the distance to be inserted or use black markings found on some tubes. 7. Curve the end of the tube by coiling the first 6 inches tightly around your finger. 8. Lubricate tip with water-soluble jelly or 2% Lidocaine jelly. 9. Tilt patient head forward. Pass the tube through the nose downward but do not force. Some people have obstructions in nasal passages. If severe resistance is met, remove the tube, lubricate and try the other nostril. 10. If patient is conscious, have them swallow. Advance the tube with each swallow. 11. After the tube has been inserted halfway, instruct the patient to talk, if there is any hoarseness or the patient is unable to speak, withdraw the tube and attempt re-insertion 12. Once tube has been inserted, verify proper placement by injecting 10 – 20 ml of air through the tube into the stomach while auscultating the stomach just below the xyphoid process. You should hear a "whooshing" sound of air entering the stomach. 13. Connect tube to suction use lowest possible setting that is effective. 14. Introduce lavage fluids (Sodium Chloride solution) in 20 – 30 ml portions and remove the stomach contents. The general rule of thumb is 20 ml in / 20 ml out. 15. Continue this lavaging until returning fluid is clear. Revision Date 11/01/2005 366 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures NASOGASTRIC TUBE INSERTION AND LAVAGE PROC 15 Page 367 TOC 16. Anchor tube to the patient's nose with tape that has been wrapped around the tube. Do not allow any pressure to be placed on the patient's nares. 17. Occasionally auscultate placement of tube during transport Revision Date 11/01/2005 367 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures NITROUS OXIDE ADMINISTRATION PROC 16 Page 368 TOC General: Following implementation of the appropriate ALS protocol, this protocol may be considered for pain management by the In-Charge. The administration of Nitrous Oxide is done using the self-administration technique (have patient hold the mask and selfadminister the gas). Indications: To provide the adult or pediatric patient relief from pain due to any of the following:  Pain due to fractures/dislocations  Burns (without airway involvement)  Significant crushing injuries to limbs  Abdominal pain (without suspected obstruction)  Renal colic  Pain due to cancer Contraindications:  Ischemic related Chest pain  Altered mental status and/or Neurologic deficits  Head trauma (with or without mental status change)  ETOH and/or Drug Overdose  Hypotension  COPD, Dyspnea  Airway burns Procedure: 1. SHOULD BE SELF ADMINISTERED 2. Turn on both oxygen and nitrous cylinders and ensure 50/50 mixture of Nitrous Oxide and Oxygen. 3. Place the facemask over the patient’s face and have the patient breath in 4 – 5 deep breaths or until they feel tingling to their face. 4. Once patient is aware of the effects, have patient use the Nitrous Oxide prn. Patient should continue to inhale gas until relief is obtained. Considerations:  An IV or saline lock may be established for use at the discretion of the EMT-P.  Nitrous Oxide should be the first line of treatment in pain relief unless otherwise indicated by patient’s condition.  Should a titer effect occur in the patient during Nitrous Oxide use, give the patient high flow oxygen until level of consciousness increases and discontinue use of Nitrous Oxide.  Attempts at pain control are not appropriate for patients with closed head injury or acute abdomen unless cause of pain has a clear etiology e.g. kidney stones.  Nitrous Oxide should not be used in the patient with a history Revision Date 11/01/2005 368 Montgomery County Hospital District-EMS ORTHOSTATIC VITAL SIGNS Clinical Guidelines – Procedures PROC 17 Page 369 TOC Indications: Orthostatic vital signs are serial measurements of blood pressure (B/P) and pulse (P) that are taken with the patient in the supine, sitting and standing positions to assess volume depletion. This test is commonly performed on patients who complain of nausea, vomiting, diarrhea, GI bleed and syncope. Contraindications:  None if performed with adequate personnel. Equipment:  Blood Pressure cuff  Stethoscope or  Electronic Measuring devices Procedure: 1. Place the B/P cuff on the patient. For consistency the same arm with the same cuff and location of pulse measurement should be used. 2. Initially, the patient needs to be supine. If the supine position compromises the patient’s breathing status or comfort level, assist them to a position that is as flat as possible. It is recommended that two (2) sets of vital signs be taken in the supine position, using the second set as the baseline. 3. The second measurement should be taken with the patient in the sitting position. The patient should be sitting upright, with their legs dangling at the side of the bed or stretcher. 4. The third measurement should be obtained with the patient in the standing position. Note: If the patient is unable to stand omit this measurement and utilize readings obtained in the sitting position. 5. One minute should elapse between measurements. 6. Findings of a decrease of 20 mm hg in systolic pressure, an increase of 10 mm hg in the diastolic pressure and an increase in heart rate of 20 beats per minute is significant. Revision Date 11/01/2005 369 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures PAIN MANAGEMENT PROC 18 Page 370 TOC Indications:  Patient meeting criteria for pain management Contraindications:  Patient that does not meet criteria for pain management. Equipment:  Appropriate equipment to monitor heart rate and rhythm, blood pressure and pulse oximetry.  Appropriate medication and administration equipment. Procedure:  Place patient on all monitors.  Have advanced airway equipment available, and medications available to treat adverse reactions.  Prepare and assemble equipment.  Prepare patient for appropriate route of administration.  Use aseptic technique throughout procedure. Treatment Options  Cognitive Therapy  Behavioral Therapy  Vascular Access  Nitrous Oxide - self administered 50% Nitrous Oxide / 50% Oxygen prn   - Fentanyl Adult:0.5 - 1 mcg/kg SLOW IV/IO, FAST IN prn • Maximum Single Dose 100 mcg • Titrate to 30-50% reduction in pain • May repeat q 5 minutes prn • Max Total administration 300 mcg Pediatric: 0.5 mcg/kg SLOW IV/IO, FAST IN prn OR   Morphine Adult: 2-4 mg SLOW IV/IO • Maximum Single Dose 4 mg • Titrate to 30-50% reduction in pain • May repeat q 10 minutes prn • Max Total administration 10 mg  Pediatric: 0.1 mg/kg Slow IV/IO - Max Single Dose 2 mg - Max Total administration 10 mg Revision Date 03/28/2011 Use extreme caution with suspicion of Alcohol or other intoxicants Ingestion 370 Montgomery County Hospital District-EMS PIV/Consult Only Clinical Guidelines – Procedures  Ketamine - Adult/Pediatric:  0.1mg/kg SLOW IV/IO, FAST IN  For muscle spasms associated with trauma (consult only):  Diazepam : - Adult: 2 – 10 mg IV / IO - Pediatric: 0.2 – 0.3 mg/kg IV / IO PAIN MANAGEMENT PROC 18 Page 371 TOC OR  Midazolam - Adult: 2 – 5 mg IV / IM / IN - Pediatric: 0.1 mg/kg IV / IM / IN Special Considerations  Rule out other possible causes of abdominal pain prior to treating any patient for kidney stones (see Abdominal Pain protocol)  Beware of synergistic effect of combining Promethazine with Fentanyl, causing profound decreases in level of consciousness, respiration, and blood pressure  Nitrous Oxide should be considered for all patients that have no cardiac / respiratory compromise  Intubation equipment and Naloxone should be readily available when administering pain medications  Pain management should begin as soon as possible in all patients and prior to other treatments in stable patients Revision Date 03/28/2011 371 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures PARAPAC VENTILATOR PROC 19 Page 372 TOC Indications:  Patients in both Respiratory and Cardiac Arrest  Patients with Profound Hypoxia evidenced by any of the following: 1. Respiratory Arrest 2. Obvious Cyanosis 3. Altered Mental Status 4. Poor air exchange upon auscultation 5. Oxygen Saturation (SpO2) below 90% Contraindications: Patients under 15 lbs. or 6.8 kg. lean body weight. Procedure: If patient is in respiratory arrest but has a pulse: 1. Attach to and turn on oxygen supply source. 2. Turn on ParaPac (Ventilation ON/OFF switch). 3. Select lowest Pressure Relief of 20cm. Select 100% Oxygen on Oxygen/Air Mix switch. 1. Ensure proper function by briefly occluding patient valve while watching pressure gauge to ensure audible pressure alarm function with relief at desired settings. 2. Attach appropriate sized ventilation mask to ParaPac Patient Valve. 3. Set Tidal Volume to initial setting that most nearly equals 3ml/lb. of patient lean body weight (6-8 ml/kg.). Adjust as needed within appropriate color coded range to achieve positive visible chest rise with positive breath sounds upon auscultation. 4. Set Breaths Per Minute (Ventilatory Rate) at 12–40 BPM. Initial Rate setting can be adjusted within the appropriate color-coded range as needed to change minute volumes. 5. Apply facemask to patient with two hands and use either head tilt and/or jaw thrust to maintain patent airway. Maintain mask seal and monitor inspiratory pressure on Pressure 6. Gauge. Increase Relief Pressure setting if needed to that which is 10 cmH2O above the minimum inspiratory pressure required to deliver the full selected Tidal Volume as determined by cessation of audible alarm, and observation of the Pressure Gauge. 7. Observe for chest rise and have second rescuer listen to both lungs for air exchange. 8. A 60cmH2O Pressure Relief setting may be used for Adults and a 40 cmH2O Pressure Relief setting may be used for Pediatrics after Endotracheal Intubation has been confirmed. Once intubated, pressure required to deliver full tidal volume may increase, but should not normally exceed 30 cmH2O– 50 cmH2O. If patient is in respiratory and/or cardiac arrest: 1. Attach to and turn on oxygen supply source. 2. Turn on ParaPac (Ventilation ON/OFF switch) Revision Date 11/01/2005 372 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures PARAPAC VENTILATOR PROC 19 Page 373 TOC 3. Select lowest Pressure Relief of 20 cmH2O. 4. Select 100% Oxygen on Oxygen/Air Mix switch. 5. Insure proper function by briefly occluding patient valve while watching pressure gauge to insure audible pressure alarm function with relief at desired settings. 6. Attach appropriate sized ventilation mask to ParaPac Patient Valve. 7. For Adult use set Tidal Volume control to volume that most nearly equals 6ml per pound of patient lean body weight (10–15 ml/kg.) or 900ml. 8. Set Ventilator Rate at 12 breaths per minute. Insure that Tidal Volume and Rate selected are color coded in the RED band. 9. For pediatric use, set Tidal Volume control to volume that is 5–6 ml/lb. lean body weight. 10. Set Rate control at setting whose color code matches that on Tidal Volume (15– 20/minute). 11. Apply facemask to patient with two hands and use either head tilt and/or jaw thrust to maintain patent airway. Maintain mask seal and monitor inspiratory pressure on Pressure Gauge. 12. Increase Relief Pressure setting if needed to that which is 10 cmH2O above the minimum inspiratory pressure required to deliver the full selected Tidal Volume as determined by cessation of audible alarm, and observation of the Pressure Gauge. 13. Observe for chest rise and have second rescuer listen to both lungs for air exchange. 14. Second rescuer finds landmark and performs chest compressions between ventilations at a ratio of 5 compressions per ventilation (5:1) for Adults and 3:1 ratio compressions/ventilation for Pediatrics. 15. A 60 cmH2O Pressure Relief setting may be used for Adults and a 40 cmH2O Pressure Relief setting may be used for Pediatrics after Endotracheal Intubation has been confirmed. Once intubated, pressure required to deliver full tidal volume may increase, but should not normally exceed 30 cmH2O – 50 cmH2O. 16. In the event of any suspected failure or problem such as failure of the chest to rise or Audible Alarm Alert / Trouble Shooting  Immediately second rescuer listens to both lungs for air exchange.  If no air exchange re-position head and mask.  If no air exchange, consider Obstructed Airway Procedures.  Check Patient Valve for foreign material or blockage.  Check patient hose connection to Control Box.  Check Pressure Gauge to observe for function.  Check all Control Settings (ON/OFF, Pressure Relief, Oxygen, Volume, Rate)  If unable to resolve the suspected problem promptly (apprx. 30 seconds or less);  Remove patient hose from ParaPac case,  Insert Universal 22mm OD mouthpiece into hose,  Blow into mouthpiece with a slow, full breath.  By auscultation listen for air exchange while watching for positive visible chest rise.  Consider Obstructed Airway procedure or alternative method of ventilation. Revision Date 11/01/2005 373 Montgomery County Hospital District-EMS PATIENT SAFETY RESTRAINT Clinical Guidelines – Procedures PROC 20 Page 374 TOC This policy shall attempt to establish guidelines to ensure the safety of EMS personnel as well as patient safety in situations when the patient may be extremely agitated and the potential for harm to self and/or others may exist. Pre-hospital Patient Restraints (PPR) should be considered whenever a patient requiring immediate medical treatment becomes a threat to himself or other emergency personnel. This should be accomplished with the least amount of force necessary to protect the patient and emergency personnel. Law enforcement officers should be requested for assistance on any patient who requires physical restraints. A blood glucose level should be obtained as soon as it is safe to do so. Whenever possible the Alarm communicator should advise responding personnel of potentially unstable or known unstable scenes and/or situations/locations when a request for EMS is received. Additionally, responding personnel are to stage for Law Enforcement personnel and should not enter the location until Law Enforcement Officers have assessed scene safety Agitation or acute behavioral disorders may manifest differently. Always suspect an organic cause first. Life-threatening organic conditions that may present with behavioral agitation are subdural hematoma, intracerebral hemorrhage, meningitis, hypertensive crises, hypoglycemia and drugs (especially atropine and cyclic antidepressants).         This procedure applies to patients being treated under implied consent and is not to be used on patients specifically refusing transport. A Supervisor consult is required before PPR is attempted. Exceptions would be imminent threat to EMS personnel by the patient that may pose immediate physical injury to EMS personnel. If EMS personnel have entered a location that becomes unstable and physical injury is threatened verbally and/or the patient or other parties on scene threaten physical harm, EMS personnel should physically remove themselves from the scene and move to a location of safety until Law Enforcement officials arrive. If necessary EMS personnel should leave medical equipment to accomplish this task. The safety of EMS personnel comes first. In all events, attempts should be made to “talk the patient down” before restraint is considered. The conversation should be honest and straightforward. EMS personnel should attempt to have equally open escape routes for both the EMS providers and the patient. Do NOT endanger yourself or other EMS personnel. At All times the safety of the medical personnel should remain first priority. Assess the patient’s mental status. Determine if the patient has suicidal or homicidal ideation. Use the minimum PPR needed to accomplish necessary patient care and ensure safe transportation and crew safety. MCHD should never use hard restraints (e.g. handcuffs, plastic ties, or leathers) to restrain patients. Acceptable restraints for EMS personnel include sheets, wristlets, and chest posey. Revision Date 12/9/2010 374 Montgomery County Hospital District-EMS PATIENT SAFETY RESTRAINT Clinical Guidelines – Procedures PROC 20             Page 375 TOC Additional manpower should be requested prior to attempting this procedure. A minimum of five (5) people should be present to safely apply PPR. Four-Point restraints (restraining both arms and both legs) are preferred. In addition to securing both arms and legs, it may be helpful to tether the hips, thighs and chest. Tethering the thighs just above the knees prevents kicking more effectively than restraining the ankles. Nothing should be placed over the patients face, head or neck. A surgical mask may be placed LOOSELY over the patient’s mouth to prevent spitting on emergency personnel. A c-collar may be applied to limit the mobility of the patient’s neck, decrease the patient’s range of motion to protect from biting as well as prevent injuries to the patient. Restraints SHOULD NEVER be placed in such a way that prevents evaluation of the patient’s mental status or interfere with necessary patient care activities. Patients should never be placed in a prone position. Patients should never be sandwiched between two (2) long spinal boards. Patients should never be transported with hands and feet tied behind their backs (hog-tied). Monitor circulation and pulses to ensure proper circulation and prevent further injury to the patient. A blood glucose level should be obtained as soon as it is safe to do so. Full documentation of all events and patient’s condition are required on the Patient Care Report (PCR) whenever Patient Safety Restraints are utilized. Continuous ECG, pulse oximetry, End Tidal CO2, and blood pressure monitoring (every 5 minutes) are mandatory while being cared for by MCHD personnel. Once patient is restrained refer to AB 03—Aggressive Behavior protocol.  All patients restrained by MCHD personnel should receive chemical safety sedation to prevent further excessive agitation and struggling against patient safety devices. Continued struggling against safety devices can lead to hyperkalemia, rhabdomyolsis and cardiac arrest. The Medical Director and Assistant Director EMS-Clinical Services should be notified anytime this procedure is initiated. This may be accomplished by alpha pager and should include patient name and transport destination for follow-up and patient outcome. Revision Date 12/9/2010 375 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures PERICARDIOCENTESIS PROC 21 Page 376 TOC General:    Cardiac tamponade is the hemodynamic result of fluid accumulation within the potential space that surrounds the heart. This may result from traumatic cardiac injury or conditions such as pericarditis. The pericardium consists of two layers, an outer fibrous layer and an inner serous layer. The potential space produced by these layers contains approximately 20 ml of fluid with similar electrolyte and protein profiles to plasma. This potential space can accumulate approximately 120 mL of additional fluid without any significant hemodynamic effects. Further fluid accumulation can result in marked increases in pericardial pressure resulting in decreased cardiac output, hypotension, and cardiac arrest. Removing as little as 30 mL may produce dramatic hemodynamic improvement.  Pericardiocentesis is the aspiration of excess fluid that has accumulated within the pericardial sac surrounding the heart. Policy:  For the purpose of this procedure pericardiocentesis is utilized ONLY in the traumatic cardiac arrest patient in accordance with the Traumatic Cardiac Arrest SDO Equipment:      Defibrillator with monitor “Three hole punch” 18 gauge or larger needle/catheter-over-needle (minimum 3 ½") Large luer-lock syringes Empty evacuated container, 1000 mL Chlorohexidine, sterile gloves Indications:   Traumatic cardiac arrest with known or suspected injury to chest and/or abdomen Completion of bilateral chest compression without return of spontaneous circulation Precautions: Pneumothorax or hemo-pneumo-pericardium may result from leaving needle open to air. Complications:  Cardiac perforation / Ventricular puncture  Laceration of coronary artery  PneumothoraxLiver laceration Revision Date 06/21/2012 376 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures PERICARDIOCENTESIS PROC 21 Page 377 TOC Procedure: 1. 2. 3. 4. 5. 6. 7. 8. 9. Identify landmarks (costal margin, xyphoid process). See attached. Cleanse site with Chlorhexidine. Use the provided needle attached to a 3-way stopcock and 60 ml syringe. Insert the needle at the xyphocostal angle approximately 45° to the chest. The catheter is directed toward the inferior tip of the left scapula. Advance the needle toward the left shoulder while applying a slight negative pressure on the syringe. The sub-xyphoid technique is the safest approach because it avoids injury to the coronary arteries. As you advance the needle into the pericardial sac you should feel a slight give. Begin to aspirate 20 – 30 ml of blood or fluid. After aspirating the fluid withdraw the needle from the chest. With a needle over catheter configuration, the catheter may remain inserted if ongoing ECG monitoring for ventricular ectopy is initiated and the catheter is secured with stopcock closed. Assess for any improvement in hemodynamic status. Signs of resolution of tamponade include:  Restoration of pulse  Improvement in vital signs, specifically ETCO2 indicative of perfusion, and hemodynamics  Relief of JVD For patients experiencing return of pulses, monitor for evidence of tamponade recurring, such as increasing JVD and decreased cardiac output. Should these occur, the procedure may be repeated or aspiration attempted from the indwelling catheter. Revision Date 06/21/2012 377 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures RAPID SEQUENCE INTUBATION- RSI PROC 22 Page 378 TOC Adult Rapid Sequence Intubation (RSI) Indication: Unable to establish or maintain a patent airway by BLS airway adjuncts/techniques or via orotracheal intubation with patient weight >45kg Contraindications: Absolute contraindications to RSI: Spontaneous breathing with adequate ventilation and a patent airway Inadequate personnel or other resources to safely carry out procedure Patient or family history of malignant hyperthermia or muscle rigidity with paralytic use Relative contraindications to RSI: History of pseudocholinesterase deficiency (applies to use of paralytic agents) Significant body surface area burns (greater than 24 hours old) (applies to use of paralytic agents) Spinal cord injury (greater than 24 hours old) (applies to use of paralytic agents) Crush injuries (greater than 24–48 hours old) Known hyperkalemia Neuromuscular diseases such as myasthenia gravis, muscular dystrophy (applies to use of paralytic agents) Concern that intubation might be unsuccessful due to: Major facial or laryngeal trauma Upper airway obstruction Distorted facial or airway anatomy Equipment Fentanyl Ketamine or Etomidate Succinylcholine Vecuronium Midazolam 2 syringes – 3 or 5 ml 2 syringes – 5 or 10 ml Endotracheal tube and stylet Laryngoscope handle & blades ET Introducer Device Bag Valve Mask, complete Revision Date 06/21/2012 Water-soluble lubricant Tape or tube securing device Oral Airway Stethoscope Suction equipment and supplies Oxygen Surgical airway kit Blind insertion airway device Monitoring equipment: ECG Pulse oximeter EtCO2 adapter(s) 378 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures RAPID SEQUENCE INTUBATION- RSI PROC 22 Page 379 TOC Procedure: 1. Prepare:  Ensure all equipment is prepared and easily accessible  Two (2) persons with local authorization to intubate should be present. Ideally, 3 or more total responders should be available. Call for the nearest BLS or ALS resource if less than 3 total emergency responders are on scene.  Ensure a supervisor is enroute or on scene  Ensure connection to all monitoring devices including ECG monitor, EtCO2, SpO2. A baseline EtCO2 value should be established. 2. Pre-Oxygenate:  100% oxygen for duration of equipment preparation.  VENTILATE PATIENT IF O2 SAT IS BELOW 92% OR EtCO2 IS ABOVE 50  Gentle BVM ventilation with cricoid pressure can be utilized as drugs are administered. Do not spend excessive time trying to raise the saturation. 3. Pressure:  Cricoid pressure should be initiated prior to succinylcholine and may be discontinued when fasciculation is resolved 4. Induction:  Ketamine 2 mg/kg IV/IO • Ketamine has analgesic properties and does not require a separate analgesic, but may not produce muscle relaxation.  If Ketamine is unavailable or contraindicated then:  Etomidate 0.3 mg/kg IV/IO Proceed to intubation (Step 5) if adequate relaxation is accomplished Neuromuscular blockade (if needed) If intubation cannot be accomplished with “Induction” If there is a reasonable belief that a non-paralyzed intubation attempt will not be successful, such an attempt is not required Administer Succinylcholine 1.5 mg/kg IV/IO Only if Succinylcholine is unavailable or contraindicated, give: Vecuronium 2- 10 mg IV/IO (PIV Consult Only) Verification of Complete Paralysis- Be alert for Jaw muscle spasm or failure to relax as a sign of possible malignant hyperthermia Revision Date 06/21/2012 379 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures RAPID SEQUENCE INTUBATION- RSI PROC 22 Page 380 TOC 5. Intubate, making the FIRST attempt the BEST attempt: (See PROC 12) Continuously monitor heart rate and SpO2 during each intubation attempt. Speak up to stop attempts in progress if desaturation or bradycardia is recognized. Prolonged BVM ventilation may be necessary in between attempts to prevent desaturation Intubation should be confirmed by multiple methods; however, EtCO2 should be the first and primary method to confirm. If not successful after 2 attempts at intubation, use Supraglottic Airway or High-Quality BVM ventilation with BLS airway adjuncts 6. Post Intubation Maintenance  Once intubation is verified, monitor closely for evidence of awareness or emergence from paralysis. There should be sufficient personnel for dedicated monitoring to assure that “paralyzed is not realized.” Achieve ongoing sedation, generally q 10 minutes unless evidence of awareness, using:  Fentanyl 1mcg/kg slow IV IO And/Or  Midazolam 2-4mg (or 0.1 mg/kg) slow IV/IO (unless using Ketamine) And/Or  If Ketamine facilitated intubation, Ketamine 1 mg/kg IV/IO  If Midazolam and Ketamine are unavailable/contraindicated, consult for further guidance  Continuous IV Sedation Infusion (PIV Consult Only) • Fentanyl Infusion (Mix 500mcg/100mL) • 25-200mcg/hour • Infused Via IV Pump  And/Or • • • Midazolam Infusion (Mix 10mg/100mL) 2-10 mg/hour Infused Via IV Pump  Ongoing Paralysis (PIV Consult Only) • Vecuronium 0.1 mg IV/IO (for prolonged paralysis) Revision Date 06/21/2012 380 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures RAPID SEQUENCE INTUBATION- RSI PROC 22 Page 381 TOC Precautions: RSI should be used with caution in patients who are dependent on their own upper airway muscle tone or specific positioning to maintain the patency of their airway (e.g. cases of upper airway obstruction by abscess or abnormal anatomy). As paralysis occurs and these patients lose their ability to maintain an airway, BVM ventilation and intubation may not be possible because of obstructions or distorted anatomy. In these patients, carefully titrated sedation and conscious intubation may be a more acceptable alternative in securing an airway. Cricoid pressure occludes the esophagus, preventing passive reflux of stomach contents into the oropharynx. Revision Date 06/21/2012 381 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures RAPID SEQUENCE INTUBATION- RSI PROC 22 Page 382 TOC Pediatric Rapid Sequence Intubation (RSI) Indication: Unable to establish or maintain a patent airway with BLS airway adjuncts/techniques or via orotracheal intubation Conditions requiring management and protection the airway Contraindications: Absolute contraindications to RSI: Spontaneous breathing with adequate ventilation and a patent airway Inadequate personnel or other resources to safely carry out procedure Prior history or family history of malignant hyperthermia or muscle rigidity with paralytic use Relative contraindications to RSI: History of pseudocholinesterase deficiency (applies to use of paralytic agents) Significant body surface area burns (greater than 24 hours old) (applies to use of paralytic agents) Spinal cord injury (greater than 24 hours old) (applies to use of paralytic agents) Crush injuries (greater than 24 hours old) Neuromuscular diseases such as myasthenia gravis, muscular dystrophy (applies to use of paralytic agents) Concern that intubation might be unsuccessful due to: Major facial or laryngeal trauma Upper airway obstruction Distorted facial or airway anatomy Equipment: Fentanyl Oral Airway Ketamine Stethoscope Midazolam Suction equipment and supplies 2 syringes – 3 or 5 ml Oxygen 2 syringes – 5 or 10 ml Surgical airway kit Endotracheal tube and stylet Blind insertion airway device Laryngoscope handle & blades Monitoring equipment: ET Introducer Device ECG Bag Valve Mask, complete Pulse oximeter Water-soluble lubricant EtCO2 adapter(s) Tape or tube securing device Revision Date 06/21/2012 382 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures RAPID SEQUENCE INTUBATION- RSI PROC 22 Page 383 TOC Procedure: 1. Prepare: Ensure all Equipment is prepared and easily accessible Two (2) persons with local authorization to intubate should be present. Ideally, 3 or more total responders should be available. Call for the nearest BLS or ALS resource if less than 3 total emergency responders are on scene. Ensure a supervisor is enroute or on scene Assure connection to all monitoring devices including ECG monitor, EtCO2, SpO2. A baseline EtCO2 value should be established. 2. Pre-Oxygenate: 100% Oxygen for duration of equipment preparation VENTILATE PATIENT WHOSE O2 SAT IS BELOW 92% OR EtCO2 IS ABOVE 50 Gentle BVM ventilation with cricoids pressure can be utilized as drugs are administered. Do not spend excessive time trying to raise the saturation of a respiratory patient whose condition may prevent improved saturation. 3. Pressure: Cricoid pressure should be initiated prior to succinylcholine and may be discontinued when fasciculation is resolved. 4. Premedication: Fentanyl 2 mcg/kg slow IV/IO, unless hemodynamic instability or other contraindication is present or Ketamine 2 mg/kg IV/IO 5. Intubate, making the FIRST attempt the BEST attempt: (See PROC 12) Continuously monitor heart rate and SpO2 during each intubation attempt. Speak up to stop attempts if desaturation or bradycardia is recognized. Intubation should be confirmed by multiple methods; however, EtCO2 should be the first and primary method to confirm. See Proc 15. 6. Post Intubation Maintenenace Once intubation is verified, monitor closely for evidence of awareness or emergence from paralysis. There should be sufficient personnel for dedicated monitoring to assure that “paralyzed is not realized.” Achieve ongoing sedation, generally q 10-15 minutes unless evidence of awareness, using: Midazolam 0.1 mg/kg IV/IO OR Ketamine 1 mg/kg IV/IO OR Fentanyl 1 mcg/kg IV/IO OR Revision Date 06/21/2012 383 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures RAPID SEQUENCE INTUBATION- RSI PROC 22 Page 384 TOC If above medications are unavailable/contraindicated, consult for guidance During Intubation Continuously monitor heart rate and SpO2 during each intubation attempt. Speak up to stop attempts in progress if desaturation or bradycardia are recognized. Prolonged BVM ventilation may be necessary in between attempts to prevent desaturation Precautions: RSI should be used with caution in patients who are dependent on their own upper airway muscle tone or specific positioning to maintain the patency of their airway (e.g. cases of upper airway obstruction by abscess or abnormal anatomy). As sedation occurs and these patients lose their ability to maintain an airway, BVM ventilation and intubation may not be possible because of obstructions or distorted anatomy. In these patients, carefully titrated sedation and conscious intubation may be a more acceptable alternative in securing an airway. Cricoid pressure occludes the esophagus, preventing passive reflux of stomach contents into the oropharynx Revision Date 06/21/2012 384 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures Revision Date 06/21/2012 RAPID SEQUENCE INTUBATION- RSI PROC 22 Page 385 TOC 385 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures Revision Date 06/21/2012 RAPID SEQUENCE INTUBATION- RSI PROC 22 Page 386 TOC 386 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures POSITIVE END EXPIRATORY PRESSURE (PEEP) PROC 23 Page 387 TOC Indication: Any patient with evidence of moderate to severe atelectasis, aspiration or alveolar infiltrate especially:  Pulmonary edema  Near drowning  Smoke or fume inhalation with severe respiratory distress. Contraindications: None Equipment:  PEEP valve  BVM, complete  Intubation equipment  ECG monitoring equipment and supplies  Oxygen Procedure: 1. ENDOTRACHEALLY INTUBATE THE PATIENT. 2. Attach PEEP valve to end adapter of BVM. 3. Attach BVM to Endotracheal tube in usual manner. 4. Ventilate patient as usual. 5. Observe ECG rhythm and vital signs closely. PEEP may cause dysrhythmias and/or changes in vitals. Discontinue or decrease PEEP if significant adverse responses occur. Revision Date 11/01/2005 387 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures PULSE OXIMETRY MONITORING PROC 24 Page 388 TOC General:  The pulse oximeter allows for the assessment of respiratory function by measuring unsaturated and saturated hemoglobin within the blood. The difference between the two is the percentage of saturation.  The percent of hemoglobin saturated with oxygen is referred to as Oxygen Saturation (SpO2 or O2 Sat)  A normal SpO2 for healthy individuals is 95–100%.  A low (93%) or falling SpO2 indicates that the airway or ventilatory status may be compromised. Indications:  Patients with suspected hypoxemia from any etiology.  Cardiac problems  Multiple system trauma  Altered level of consciousness Precautions:  The pulse oximeter interprets carboxyhemoglobin (COHb) as saturated hemoglobin and provides a falsely elevated reading.  Additionally, high oxygen saturation is not an indicator of sufficient oxygen delivery to the tissues, as this depends on cardiac output, and the amount of hemoglobin and level of vasoconstriction present.  Pulse oximetry readings may be difficult to obtain in states of low perfusion. (Shock ) Procedure: 1. Ensure patency of the airway and manage as indicated. 2. The probe should be applied to a finger or toe. 3. Best probe site in adults is usually the middle fingertip with nail polish removed. 4. Turn the machine on 5. A radial pulse should be taken to evaluate heart rate reading on monitor. Pediatric Considerations:  Special probes may be required to obtain readings in pediatric patients. Special Notes:  Attempt to obtain and document pulse oximetry readings before and during oxygen therapy.  The use of pulse oximetry as a vital sign is encouraged, as the oximeter may be helpful in detecting hypoxia not evidenced by signs or symptoms.  Application to pulseless or cold extremities may result in inaccurate determinations of hemoglobin saturation.  False readings may be indicated by extremely rapid changing or fluctuating readings.  Patients with hemoglobin disorders such as carbon monoxide poisoning and anemia may give artificially high SpO2 readings. Readings in such patients should be interpreted with extreme caution.  Excessive probe movement may alter accuracy of reading.  Optical interference by bright light (direct sunlight, fluorescent and xenon arc lighting). Cover the sensor.  Poor waveforms/signals (hypovolemia, hypothermia, profound hypotension, or vasoconstriction) Revision Date 11/01/2005 388 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures SPINAL MOTION RESTRICTION PROC 25 Page 389 TOC Indications:  Complaint of pain or tenderness in the spine or back that is secondary to trauma  Multiple systems trauma  Complaints and/or signs of numbness or weakness in an extremity secondary to trauma  Patient with Decreased LOC (including patients altered by the influence of drugs and alcohol) with a high suspicion of trauma.  Signs of face, head, or neck trauma, (lacerations, contusions, nose bleeds, etc.).  Any unconscious patient who may be a victim of an accident or fall. Precautions: Moving the head into a neutral in-line position is contraindicated if:  There is pain and/or muscle spasm upon movement.  Patient holds head angulated (tilted) to the side and is unable to move it.  The maneuver cannot be safely due to limited space or other conditions. In these cases the patient should be immobilized in the position in which he/she is found. Procedure: 1. Ensure adequacy of airway 2. Assess the head and neck for obvious injuries and distended neck veins while providing manual neutral in-line immobilization for the head and neck. 3. Treat any life threatening conditions 4. Apply an appropriate size cervical collar and continue to manually maintain neutral in-line immobilization. 5. Secure the patient to a long spine board/short board/K.E.D. The short board and K.E.D. are for extrication only. The patient should then be placed on a longboard. 6. Ensure that the alignment is maintained while the torso, then the head and the rest of the body are properly secured. After the patient is properly secured to the spine board manual immobilization can be released. 7. Treat other injuries 8. Transport Revision Date 11/01/2005 389 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures SURGICAL AIRWAY PROC 26 Page 390 TOC CRICOTHYROIDOTOMY Indication  To provide an emergency airway when other means have failed  Needle cricothyrotomy/jet ventilation inadequate or prolonged  Needle cricothyrotomy/jet ventilation impossible or inappropriate  This is the method of last resort at establishing an airway Procedure 1) Cricoid pressure shall be applied and maintained continuously. 2) Prepare and assemble all equipment 3) 4) 5) 6) 7) 8) 9) 10)  #11 or #15 scalpel  Endotracheal tube  Stylet or Eschmann Tracheal Tube Introducer  10 ml syringe The cricothyroid membrane is the preferred site and should be identified by the attendant performing the skill. If, due to trauma or obstruction at this level, the cricothyroid membrane is inaccessible, a site two finger-breadths above the sternoclavicular notch should be identified and utilized. Prepare the site with a Betadine and/or alcohol solution Make a 1.5–2 cm vertical incision through the skin overlying the cricothyroid membrane. Bluntly dissect the skin and fatty tissue overlying the trachea to visualize the cricothyroid membrane Make a horizontal incision through the cricothyroid membrane into the trachea. Insert the scalpel handle into the tracheal incision and twist 3–4 times (If a larger opening is required, a gloved finger can be inserted into the trachea to enlarge the opening) Form the distal end of the endotracheal tube into the shape of an “L” utilizing the stylet. Insert the tube within the trachea, remove the stylet, and inflate the cuff. Revision Date 11/01/2005 390 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures SURGICAL AIRWAY PROC 26 Page 391 TOC QUICKTRACH SURGICAL AIRWAY Indications:    Critical patient in whom a patent airway cannot be maintained or established by oropharyngeal or naso-pharyngeal airway, BVM or Orotracheal Intubation. Patient cannot receive adequate respiratory assistance with BVM and supplemental O2 after a failed RSI attempt. Critical patient with severe maxillo-facial-trauma, inflammation or severe swelling of the airway or other mechanism resulting in a life-threatening airway compromise. Contraindications:  An airway obtainable by any other means. Equipment:     QuickTrach Surgical Airway Kit BVM w/supplemental oxygen Ventilator Stethoscope Procedure:  Prepare and assemble equipment.  If possible, hyperventilate the patient.  Disinfect the area of procedure.  For Non-Traumatic patients hyperextend the neck.  Locate the cricothyroid membrane.  Place finger on thyroid cartilage (“Adams apple”) and  Move finger down into soft depression between thyroid cartilage and cricoid cartilage (next firm “bump”).  For trauma or obstruction, site two fingerbreadths above the sternoclavicular notch should be identified and utilized.  Perforate tissue at a 90 degree angle with device.  Aspirate while inserting the device.  After insertion, change angle of insertion to 45 degrees and advance until stopper hits the skin.  Remove the stopper.  Hold needle in place while advancing the plastic cannula.  Withdraw needle and advance cannula until the cannula is flush with the skin.  Secure device with the strap and attach 15 mm connector.  Ventilate patient w/BVM and supplemental oxygen.  Apply ventilator for transport. Revision Date 11/01/2005 391 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures TERMINATION OF MEDICAL RESUSCITATION PROC 27 Page 392 TOC Purpose Termination of advanced life support efforts in the pre-hospital setting applies to situations in which patients experience a non-traumatic cardiac arrest. The decision to implement the policy may be initiated by the Supervisor or the In-Charge Paramedic on scene in accordance with the standing orders set forth in this policy by the Montgomery County Hospital District-E.M.S. Medical Director. Field terminations require Supervisor consult (unless advanced medical authorization). Procedure Resuscitation efforts should not be terminated in patients meeting the following criteria: 1. The patient who has a return of a spontaneous pulse-even a transient pulse. 2. The patient who demonstrates any neurological signs {i.e. spontaneous eye opening or spontaneous movement}. 3. The patient who has suffered cardiac arrest while in the care of MCHD-EMS personnel. 4. The patient who does not have a secure endotracheal tube (includes Combitube) in place and a patent IV. Resuscitation efforts may be terminated in patients meeting the following criteria: 1. EMS should address any sudden external causes of cardiac arrest {i.e. overdose, toxic exposure, hypo/hyperthermia, submersion, electrocution, burns, trauma, airway obstruction} 2. The patient should have been intubated (includes Combitube) successfully and have had vascular access and standard advanced life support measures applied throughout the resuscitation. 3. Resuscitative efforts should continue at least 20 minutes after ALS interventions have begun regardless of previous CPR time and arrest interval. 4. The patient whose ECG rhythm is persistent ventricular fibrillation, pulseless ventricular tachycardia, PEA (after potential causes addressed) and asystole. If the patient remains unresponsive to advanced life support measures and meets the criteria above, the Supervisor (unless advanced medical authorization) should be contacted before resuscitative efforts are terminated. In the event that any family member or responsible party indicates their objection to the concept of termination of resuscitative efforts, the resuscitation efforts shall continue until the receiving emergency room physician assumes care. Once the decision has been made to terminate resuscitative efforts, the EMS crew shall tie off and knot all established IV lines close to the site and remove the IV fluid bag and any other supplies at the code site. The IV catheters and endotracheal tube should remain in place. Revision Date 07/26/2010 392 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures TERMINATION OF MEDICAL RESUSCITATION PROC 27 Page 393 TOC The Supervisor or In-Charge paramedic shall contact the Communications Center for the notification of code being terminated and to call law enforcement if not already on scene. At all times MCHD-EMS personnel shall be attentive to the psychological needs of the “survivors” and provide support as needed. If outstanding circumstances exist, patient should be transported. Field termination is an option not a directive. The Attending Medic should contact LifeGift with patient information. Revision Date 07/26/2010 393 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures TOURNIQUET USE PROC 28 Page 394 TOC Assessment Requirements: Trauma Assessment Indication • • • • Life threatening extremity hemorrhage that cannot be immediately controlled by other means Serious or life threatening extremity hemorrhage and tactical considerations prevent the use of standard hemorrhage control techniques Devastating extremity injury with signs of shock Bleeding from indwelling catheter / fistulae / shunt in extremity that cannot be controlled through other means Acceptable Use • • • • If time and manpower available, apply direct pressure If direct pressure fails or if time and / or manpower not available, apply tourniquet o Commerical tourniquet is preferred, if not available a cravat or similar device is acceptable If injury is to leg and bleeding is not controlled with the first tourniquet, place a 2nd tourniquet distal and immediately adjacent to the 1st If a tourniquet is initially applied, gradual removal of a tourniquet is acceptable if bleeding can later be controlled by direct pressure Procedure for applying Tourniquet • • • • Apply proximal to injury away from joint Tighten until bleeding is controlled Secure windlass with all available security features Inform hospital staff of tourniquet use and time of application Note: Typical EMS contact time is less than the ischemic time required for permanent damage to limb. The most common error involving tourniquets is failure to apply when indicated. Revision Date 06/21/2012 394 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VAGAL MANUEVERS PROC 29 Page 395 TOC Indications:  Narrow Complex Tachycardia Contraindications:  None for Valsalva maneuver Equipment Needed:  Personal protective equipment  ECG monitor  Vascular Access established  Oxygen  Emergency medications and equipment should be immediately available. Procedure: 1. Ensure that patient is on oxygen, has a patent vascular access, and is on a cardiac monitor. 2. Record the ECG rhythm continuously while performing all Vagal maneuvers. 3. Instruct the patient to cough forcefully several times. If this is ineffective proceed to the Valsalva maneuver. Valsalva Maneuver: 1. Have the patient take a deep breath and “bear down" against a closed glottis, as if trying to "clear" or "pop" his or her ears. Have the patient perform this for as long as they can. (Alternative method: Remove plunger from a small syringe and instruct patient to blow through small end.) 2. If no conversion, repeat the procedure, up to three attempts total. 3. If still no conversion and not contraindicated, proceed with carotid sinus massage. Revision Date 11/01/2005 395 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VAGAL MANUEVERS PROC 29 Page 396 TOC Carotid Sinus Massage Contraindications:  Presence of carotid bruit  Unequal carotid pulses  Patient < 4 years old or >50 years old  Diagnosis of prior CVA or carotid surgery Procedure: 1. Place the patient supine or semi-fowler with neck extended. Separately palpate each carotid artery for pulse quality, and auscultate both for bruits. 2. Tilt patient's head to one side and locate the right carotid sinus adjacent to the carotid pulse. 3. Using 2–3 fingers, press firmly over carotid sinus toward cervical vertebrae and massage up and back in a circular motion. Never massage both carotid arteries at the same time. 1. Discontinue the procedure after any of the following:  After 20 seconds  The first indication of conversion  At first sign of slowing heart rate or heart block.  If patient experiences dizziness or altered level of consciousness. 2. If no conversion after the first attempt, repeat the procedure once. 3. If still unsuccessful and patient condition warrants, administer an appropriate pharmacological agent. Revision Date 11/01/2005 396 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VASCULAR ACCESS PROC 30 Page 397 TOC IV THERAPY PROCEDURE Indications: Intravenous access shall be obtained when the clinical assessment indicates the necessity of medication administration, fluid replacement and/or resuscitation. General Standards:  Vascular access can be accomplished by a saline lock (see appropriate procedure) or peripheral venous infusion  In all pediatric patients receiving intravenous fluids, a buretrol administration set should be used and delivery of fluids should be monitored. If non-traumatic / non-shock medical patient: 1. Appropriate size catheter or butterfly needle (usually 16G, 18G or 20G) 2. Microdrop administration set (60gtt/ml) 3. Extension set 4. Normal Saline (0.9% NS) 5. Run at KVO rate (15–30 ml/hour) or rate specified by protocol. 6. Saline Lock: If trauma patient or shock symptoms present: 1. Large bore catheter when possible (usually 14G or 16G)  If shock is present use 2 large bore IVs. 2. Standard administration set (10–15gtt/ml) or blood administration set. 3. Blood Tubing: The use of blood administration tubing is recommended in place of standard IV sets for patients that may require blood transfusion or rapid fluid infusion 4. Normal Saline (0.9% NS) 5. Run at rate specified by protocol Complications:  Infection  Air embolism  Catheter shear  Hematoma  Arterial puncture Revision Date 03/28/11 397 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VASCULAR ACCESS PROC 30 Page 398 TOC Equipment:  Appropriate size and type IV/IO catheter  Appropriate administration set  Chlorohexidine or alcohol preps  5–10 ml syringe  IV start kit  Dressing and tape or commercial securing device ("Venigard", Opsite")  Blood draw set up Note: DO NOT risk loss of the IV site to perform a blood draw. Blood can be obtained later at the receiving facility. Procedure for Peripheral Cannulation: 1. Don appropriate personal protective gear 2. Explain the need for IV administration and describe what will be done 3. Check the IV solution for expiration date, cloudiness, etc. 4. Spike the bag with the appropriate IV tubing 5. Remove air from IV tubing 6. Place the tourniquet on the extremity 7. Select the site (Preferred IV site for patients in cardiac arrest is the antecubital fossa) 8. Cleanse the skin with Chlorohexidine or alcohol prep 9. Make puncture while maintaining vein stability 10. Watch for flashback. If you have no blood return and you are in the vein, remove the needle hub and attach your syringe to assist in aspirating for blood. Once you have a blood return, advance the catheter as per normal IV technique and attach the IV tubing. 11. Remove the tourniquet 12. Begin IV fluid therapy. Observe the site for redness, edema or other indications of infiltration. 13. Secure catheter and IV tubing (remember Not to restrict other vascular structures by applying dressing too tight) Considerations: Initiation of vascular access generally should not delay patient transport to the hospital. Whenever possible: 1. Do not place IV on side of injured arm or chest. 2. Avoid using lower extremities unless last resort. 3. Do not place IV on side of previous mastectomy. 4. Do not place IV on side of stroke or paralysis. 5. Hickman catheters or other indwelling IV access ports should be used only if unstable patient condition necessitates an IV, and no other access is available. 6. DO NOT USE RENAL SHUNTS. Revision Date 03/28/11 398 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VASCULAR ACCESS PROC 30 Page 399 TOC EXTERNAL JUGULAR CANNULATION Indications: For infusion of fluid or administration of medications in any urgent/critical patient in whom vascular access cannot be obtained in 3 attempts at other peripheral sites. EJV cannulation may be considered as first-line vascular access in cardiac arrest or severe hypovolemic / hypotensive crisis. 1. Don appropriate personal protection gear. 2. Select and prepare equipment. Attach 10 ml syringe to hub of catheter/needle to assist in identification of placement in patients with low or now cardiac output. 3. Clear air from tubing. 4. Place the patient in a supine, trendelenburg position. 5. Identify external jugular vein. 6. Prepare the site with alcohol or Chlorohexidine. 7. Place a finger above the clavicle to facilitate filling the vein. (this should also assist with stabilization of site). 8. Make your puncture midway between the angle of the jaw and the middle of the clavicle while maintaining vein stability with your finger. 9. Watch for flashback. If you have no blood return and you are in the vein, remove the needle hub and attach your syringe to assist in aspirating for blood. Once you have a blood return, advance the catheter as per normal IV technique and attach the IV solution. 10. DO NOT ALLOW AIR TO ENTER THE CATHETER ONCE IT HAS BEEN INSERTED. Remember to cover the catheter with gloved finger while preparing to attach the IV tubing. 11. DO NOT risk loss of vascular access to perform a blood draw. 12. Initiate IV fluid therapy. Observe site for redness, edema or other indications of infiltration. 13. Secure IV catheter and tubing. A cervical collar may be useful to prevent mobility and ensure that the catheter does not dislodge. 14. Two attempts are allowed on one side. NEVER attempt cannulation on both external jugular veins. 15. Consider I/O if all other attempts are unsuccessful. Complications  Air embolism  Pnuemothorax  Infection  Catheter shear  Hematoma  Arterial puncture  Fluid overload Considerations:  Initiation of vascular access generally should not delay patient transport to the hospital. Revision Date 03/28/11 399 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VASCULAR ACCESS PROC 30 Page 400 TOC SALINE LOCK Indications: Injection locks may be used to secure venous access in any of the following situations:  The EMS personnel do not anticipate the immediate need for administering IV medications or IV fluid in the pre-hospital setting at the discretion of the technician. The saline lock should be flushed periodically in extended transport situations.  The EMS crew has already secured a patient IV line for medications and fluid but anticipate a second IV site or "backup" will should be required. (i.e. Acute MI, CVA)  The patient be receiving IV adenosine. In this situation, personnel should have a second IV established with large bore catheter of NS. Equipment: 1. Don appropriate protective gear. 2. Consider Nitrous Oxide prior to attempt (especially in pediatric patients). 3. Explain the procedure. If the patient is a child DO NOT lie regarding the amount of discomfort involved with the procedure. You may lose all credibility with your patient. 4. Assemble and prepare equipment. Attach all components of injection lock 5. Establish IV with angiocath in usual manner 6. Once needle is removed, attach injection lock to catheter. 7. Flush lock and catheter with 5 ml of normal saline 8. Observe site for redness, edema or other indications of infiltration 9. If patent, secure IV catheter in usual manner Complications:  Infection  Air embolism  Catheter shear  Hematoma  Arterial puncture Considerations: Initiation of vascular access generally should not delay patient transport to the hospital. Whenever possible: 1. Do not place IV or saline lock on side of injured arm or chest. 2. Avoid using lower extremities unless last resort. 3. Do not place IV on side of previous mastectomy. 4. Do not place IV on side of stroke or paralysis. 5. Hickman catheters or other indwelling IV access ports (not renal shunts) should be used only if unstable patient condition necessitates an IV, and no other access is available. Revision Date 03/28/2011 400 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VASCULAR ACCESS PROC 30 Page 401 TOC EZ-IO ACCESS DEVICE - ADULT Indication: Any adult patient (>45 kg) for who, you are unable to obtain peripheral vascular access after 2 attempts or 90 seconds and that has one or more of the following:  Hemodynamic instability  Respiratory compromise  Patients requiring EMERGENCY medicinal therapy or volume replacement May be used without consult in Cardiac Arrest & Post Resuscitation Management Consult Required for Placement in all other patients  Any patient that treatment warrants vascular access, but peripheral access has been unobtainable  UNDER NO CIRCUMSTANCES should it be used for prophylactic care Contraindications: 1. Patient’s weighing less than 45 kg. 2. Any patient that may receive fibrinolytic or thrombolytic therapy; specific to Active MI and/or Stroke. 3. Hypoglycemic patients needing D50; EXCEPTION ONLY is Cardiac Arrest. 4. Suspected fracture of the associated tibia or femur. 5. Previous orthopedic procedures: i.e., knee replacement 6. Extremity that is compromised by a pre-existing medical condition. i.e. tumor or PVD 7. Overlying skin infection/trauma at placement site 8. Inability to locate the 3 anatomical landmarks for insertion, which are the patella, tibial tuberosity, and 1 finger width medial of the tibial tuberosity. 9. Excessive tissue over the insertion site. 10. Patient’s at risk of NO Transport: i.e., Unconscious Hypoglycemic (Diabetic) Equipment:  EZ-IO™ Driver  EZ-IO™ Needle Set  Chlorohexidine or prep pads  IV setup and/or optional extension tubing  10 ml or 20 ml Syringe  Roller gauze  Lidocaine 100 mg/5ml pre-load syringe (for conscious patients) Revision Date 03/28/2011 401 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VASCULAR ACCESS PROC 30 Page 402 TOC Procedure: i. Don PPE ii. Determine if EZ-IO™ is indicated and no contraindications are present. iii. Locate proper site for EZ-IO™ insertion. a. Feel the front surface of the leg and locate the patella. b. Locate the tibial tuberosity inferior to the patella. c. Place 1 finger medial of the tibial tuberosity. Insertion location is 1 finger width medial of the tibial tuberosity. iv. Cleanse the insertion site with Chlorohexidine or similar prep-pads using accepted aseptic technique. Remember to work from the inside to the outside in concentric circles. v. If patient is conscious, inform patient of the EMERGENT need to perform procedure and that they might feel some discomfort until Lidocaine is administered. Obtain consent from patient; recall that the patient has the right to refuse. vi. Consider an anesthetic/analgesic if indicated by medical direction. vii. Prepare the EZ-IO™ Driver and Needle Set. a. Open the cartridge and attach the needle set to the driver b. Remove needle set from the cartridge. c. Remove the cap from the needle set. viii. Begin insertion of the EZ-IO™ a. Hold the EZ-IO™ Driver in one hand and stabilize the leg near the insertion site with the opposite hand. b. Position the driver at the insertion site at a 90o angle to the bone surface. c. Power the driver through the skin at the insertion site until it makes contact with bone. d. Evaluate the EZ-IO™ needle for the 5 mm mark ix. Power the EZ-IO™ Driver and continue insertion until the flange (base) of the EZ-IO™ needle set touches the skin OR a sudden lack of resistance is felt, indicating entry into the marrow cavity. x. Remove the driver from the needle set. xi. Remove the stylet from the catheter. DO NOT REPLACE or ATTEMPT to recap the needle set. xii. Confirm proper EZ-IO™ Catheter tip position by checking for at least 1 of the following: a. IMMEDIATELY SYRINGE FLUSH with at least 10cc of fluid b. IO catheter standing at 90o and firmly seated in tibia. c. Blood at tip of the stylet. d. A free-flow of fluid through the needle with no evidence of extravasation. DO NOT ASPIRATE xiii. Connect IV tubing and begin infusion. An extension set is recommended but not required. xiv. If site does not flow, consider pressure infusion, reflush and/or rotate needle 180o. Consider a combination of these procedures and repeat as necessary. xv. Dress site with roller gauze to prevent accidental dislodgement. IF PATIENT IS CONSCIOUS FOR PROCEDURE 1. Administer bolus 50 mg (2.5 ml) of Lidocaine 2% SLOW push for local analgesia. This will provide pain relief for up to 1 hour. 2. Consider pain management for additional discomfort/pain associated with infusion. Revision Date 03/28/2011 402 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VASCULAR ACCESS PROC 30 Page 403 TOC EZ-IO ACCESS DEVICE - PEDIATRIC Indications:  IO placement is limited to patients under 6 years of age OR  CRITICALLY ill or injured child in whom vascular access cannot be established peripherally in 2 attempts within 90 seconds.  IO placement Should Not be attempted on conscious pediatric patients unless loss of life or limb could result if treatment is withheld.  Consider the use of Nitrous Oxide for conscious patients if procedure is deemed necessary prior to attempting IO procedure for anxiety. Contraindications:  History of chronic bone disease  Osteomyelitis  Fracture or trauma to site ---Exception: Minor to moderate burns if no other IO site is available. General:  Flow rates for all IO’S are to be at TKO unless otherwise indicated by specific protocol or Medical Control. Equipment:  13 to 18 ga intraossesous needle  Chlorohexidine  10 ml syringe  Tape  4 x 4’s  3 inch roller gauze  Complete IV set up, including fluid and tubing  Lidocaine 100 mg/5ml pre-load syringe (for conscious patients) Procedure: 1. Select and prepare equipment. Don personal protective equipment. 2. Expose and stabilize the lower extremity to minimize motion. 3. Identify the proximal tibia and place sandbags or rolled towels under the knee. 4. Insert the needle, one finger's breadth below the tibial tuberosity or slightly medial to midline, perpendicular to the skin, directed away from the growth plate, and advance to the periosteum. The bone is penetrated with a slow boring or twisting motion until you feel a sudden "give" (decrease in resistance) as the needle enters the marrow cavity. 5. Stop advancing the needle. 6. Attempt to confirm marrow placement by removing the stylet and aspirating blood and bone marrow. (Absence of marrow does not necessarily indicate incorrect placement). 7. If unable to aspirate, attach 10ml syringe with Normal Saline and gently infuse Normal Saline. 8. Observe for infiltration or SQ tissue swelling. If no swelling noted, proceed. If swelling is noted select a different site. Revision Date 03/28/2011 403 Montgomery County Hospital District-EMS Clinical Guidelines – Procedures VASCULAR ACCESS PROC 30 Page 404 TOC 9. Connect the IV tubing 10. Stabilize the entire intraosseous set-up as if to secure an impaled object. Complications:  Complications include subperiosteal infusion, osteomyelitis, sepsis, fat embolism, and bone marrow damage.  If infiltration occurs (rare), do not reuse the same bone, select another site. Considerations:  Initiation of vascular access generally should not delay patient transport to the hospital. IF PATIENT IS CONSCIOUS FOR PROCEDURE 1. Administer bolus 0.5 mg/kg Lidocaine 2% (max 50mg) SLOW push for local analgesia. This will provide pain relief for up to 1 hour. 2. Consider pain management for additional discomfort/pain associated with infusion. Revision Date 03/28/2011 404 This Page Intentionally Left Blank MED REFERENCE Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference ACETAMINOPHEN MED REF Page 407 TOC (Tylenol, APAP) Medication An analgesic / antipyretic that has weak anti-inflammatory activity and no effects on platelets or bleeding time Mechanism of Action Reduces fever by acting directly on the heat regulating center of the hypothalamus. Indications Fever of any etiology Contraindications Hypersensitivity Side Effects Rarely, gastric irritation Dosage and Administration ADULT: 650–975 mg PO or PR PEDIATRIC: 15mg/kg PO or PR Acetaminophen Dosing Concentration: 325 mg / 10.15 ml Age 0–3 mo 6–-11 mo 12–23 mo 2–3 yrs 4–5 yrs 6–8 yrs 9–10 yrs 11 yrs Weight (lbs) Dose 6–11 40 mg/ 1.25 ml 12–17 80 mg/ 2.5 ml 18–23 24–35 36–47 48–59 120 mg/ 3.75 ml 160 mg/ 5 ml 240 mg/ 7.5 ml 320 mg/ 10 ml 60–71 72–95 400 mg/ 12.5 ml 480 mg/ 15 ml Special Considerations • Doses may be repeated q 4 hrs prn not to exceed 75 mg/kg total per 24-hour period. • Do not administer if last administration was < 4 hours ago. • Hepatic damage begins at overdoses of ≈ 150 mg/kg. Revision Date 11/01/2005 407 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference ACTIVATED CHARCOAL MED REF Page 408 TOC (Sorbitol) Medication Activated charcoal is an absorbent compound suspension with cathartic. Each milliliter contains 208 mg of activated charcoal and 400 mg Sorbitol. Mechanism of Action Activated charcoal is pharmacologically inert and is not absorbed in the gastrointestinal tract. It adsorbs a variety of organic and inorganic substances. Once bound by the charcoal in the gut, toxins are inactivated and excreted. Under appropriate physiologic conditions, activated charcoal absorbs toxins instantaneously. Indications • Only used after the stomach has been evacuated. • Ingestion of certain poisons or excessive amounts of certain medications. • Especially useful in Aspirin, Amphetamines, Strychnine, Dilantin, T.C.A. and Phenobarbital overdoses. Contraindications • Should not be administered before, or in conjunction with, Syrup of Ipecac. If syrup of Ipecac is being used to produce emesis, administration of Actidose charcoal should be delayed 30 – 60 minutes after the conclusion of emesis. • Should not be given in cyanide poisoning or corrosive substances. • Is of no value in poisoning due to methanol, iron tablets, and organophosphates Side Effects • Aspiration of charcoal has been reported to produce airway obstruction. • Gastrointestinal obstruction from charcoal may occur as a consequence of toxininduced antiperistaltic effects. Dosage and Administration • Prior to administration, shake the container thoroughly for a minimum of 30 seconds. After administration, the container should be thoroughly rinsed with water and any residue should be administered to the patient to ensure that the entire dose has been delivered. ADULTS: 50 – 100 grams May be given PO or NG tube Special Considerations • If patient is unconscious or has ingested a substance that may result in LOC, have patent airway secured before administration of charcoal. Revision Date 11/01/2005 408 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference ADENOSINE MED REF Page 409 TOC (Adenosine) Medication A naturally occurring endogenous purine nucleoside found in all body cells. It is primarily formed from the breakdown product of adenosine triphosphate (ATP). Adenosine slows tachycardias associated with the AV node via modulation of the autonomic nervous system without causing negative inotropic effects. Mechanism of Action • It acts directly on sinus pacemaker cells and vagal nerve terminals to decrease chronotropic and dromotropic activity. • Adenosine slows electrical conduction through the A-V node and can interrupt the re-entry pathways through the A-V node. • Onset: 5 –10 seconds • Duration: 10 seconds Indications • PSVT • PSVT associated with Wolff-Parkinson-White Syndrome. • Diagnostic for stable, wide complex tachycardias of unknown origin. • Not for the treatment of Atrial Flutter or Fibrillation; however, if mistakenly administered to patients in these arrhythmias, the decrease in A-V conduction may unmask atrial activity. Contraindications • 2° or 3° A-V block – Except in patients with a artificial pacemaker • Sick Sinus Syndrome – Except in patients with a artificial pacemaker • Use with caution in pregnant women. • Use with caution in patients who are wheezing Side Effects • Due to the very short half-life of Adenosine (≈ 10 sec.), these side effects should be short lasting. • May produce short lasting arrhythmias at time of conversion: • PVC’s • PAC’s • Sinus Bradycardia / Asystole / IVR • A-V blocks: Patients who develop high grade block after administration of • one dose should not be given additional doses. Revision Date 03/29/2006 409 Montgomery County Hospital District-EMS ADENOSINE Clinical Guidelines – Medicine Reference • MED REF Page 410 TOC May produce any of the following: 1. 2. 3. 4. Chest Tightness Shortness of Breath / Dyspnea Bronchoconstriction Lightheadedness 5. 6. 7. 8. Headache Vertigo Facial Flushing Nausea. Dosage and Administration • Adenosine should be given as a rapid bolus intravenous injection. • It should be given as proximal as possible and followed by a rapid fluid flush (at least 10 ml). ADULT: Initial: Repeat: PEDIATRIC: Initial: Repeat: 12 mg RAPID IV/IO (1–2 sec) If 1st dose is unsuccessful, administer 12 mg RAPID IV/IO - The 12 mg dose may be repeated once if needed (maximum 24 mg dose). 0.1 mg/kg RAPID IV/IO If 1st dose unsuccessful, administer 0.2 mg/kg RAPID IV/IO Special Considerations • Treatment of any prolonged adverse effects should be individualized and directed towards the specific event. • Due to the antagonistic effect of methylxanthines (caffeine and Theophylline), larger doses of Adenosine may be necessary in the presence of methylxanthines. • Due to the potentiation by dipyridamole (Persantine), smaller doses of Adenosine may be effective in the presence of dipyridamole. • Adenosine is not blocked by Atropine. • Remember the Valsalva maneuver. • Record 3 lead ECG prior to use of Adenosine • Rapid injection with a flush of 10–20 ml of saline, into the IV line increases likelihood of success. Revision Date 03/29/2006 410 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference ASPIRIN MED REF Page 411 TOC (Acetylsalicylic Acid, ASA) Medication Aspirin (Acetylsalicylic acid) is an analgesic, antipyretic, and anti-inflammatory. It also inhibits platelet aggregation thus making it a beneficial anti-thrombolytic. Mechanism of Action Aspirin inhibits the synthesis of thromboxane A2, which induces platelet aggregation, by inhibiting a metabolic enzyme necessary for its production. Aspirin is rapidly absorbed from stomach and small bowel. Indications • Ischemic chest pain • Suspected Myocardial Infarction Contraindications • Hypersensitivity to salicylates and its derivatives. • Previous reactions (e.g. asthma, angioneurotic edema, uticaria, rhinitis) • Current anticoagulant therapy • Known or suspected active hemorrhage or bleeding tendency. Side Effects • Prolonged bleeding time • Gastric irritation • N/V Dosage & Administration 4 tablets (81 mg chewable tablets) PO (Baby Aspirin) Special Considerations • ASA should be administered to patients on anticoagulants and regardless of prior ASA use. Revision Date 11/01/2005 411 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference ATROPINE SULFATE MED REF Page 412 TOC Medication Atropine is a naturally occurring autonomic nervous system inhibitor extracted from the Atropa belladonna plant (deadly nightshade). Mechanism of Action • Blocks parasympathetic (vagal) action on the heart. 1. Improves cardiac output by ↑ rate of sinus node discharge. 2. ↑ conduction through the A-V junction • By ↑ heart rate to normal range, Atropine ↓ the chance of ectopic activity in the ventricles. Indications • Sinus Bradycardia when accompanied by PVC’s, hypotension or other symptoms of poor perfusion. • 2° or 3° AVB when accompanied by bradycardia • Organophosphate poisoning • In Neurological injuries with a heart rate < 60 and hypotensive. Contraindications • Atrial flutter or Atrial fibrillation when there is rapid ventricular response. • History of glaucoma should be given atropine with caution. Side Effects • Blurred vision, Pupillary dilation • Headache • Dry mouth, thirst Dosage & Administration ADULT: • Bradycardia: 0.5 – 1 mg IV/IO or 2 mg ET q 5 min (Max. 0.04 mg/kg) • Organophosphate Poisoning: 2 mg IM or IV/IO q 5 min. • 0.1 to 0.5 mg IM single dose only to prevent hypersalivation. Do not Repeat. PEDIATRIC: 0.02 mg/kg IV/ET/IO (0.04 mg/kg for ET) • Minimum single dose 0.1 mg • Max. single dose 0.5 mg • May be repeated X 1 Special Considerations • May precipitate VTach or VFib, use with caution in the AMI setting. • Doses < 0.5 mg, or a dose given too slowly, may ↓ rather than ↑ the heart rate. Revision Date 03/28/2011 412 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference BENADRYL MED REF Page 413 TOC (Diphenhydramine) Medication An antihistaminic agent, benadryl is a crystalline powder, freely soluble in water and alcohol. Mechanism of Action Diphenhydramine produces anticholinergic (drying) and sedative effects. Strongly opposes the action (dilation and leakiness) of histamine on the capillary bed by binding with the histamine H2 receptor site. • • • Diphenhydramine blocks histamine effects that are caused by allergic reactions. It reverses the extrapyramidal side effects of phenothiazines. (Haldol) Diphenhydramine reduces or prevents motion sickness. Indications • Anaphylactic shock and severe allergic reaction • Extrapyramidal reactions (Dystonia) caused by the use of phenothiazine medications. • Motion sickness Contraindications • Pregnancy • Asthma • Glaucoma Or Prostate Problems • Known alcohol or depressant abuse Side Effects • Drowsiness, confusion, sedation • Blurred vision • Dry mouth • Dysuria and urinary retention • Wheezing due to thickening of bronchial secretions • Excitability in pediatric patients Dosage & Administration ADULTS: 50 mg IV/IM/IO or 25 mg IV / 25 mg IM PEDIATRIC: 1–2 mg/kg IV/IM/IO (not to exceed 50 mg IV Single dose) Revision Date 02/28/2011 413 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference BENADRYL MED REF Page 414 TOC Special Considerations • Diphenhydramine should be used as an adjunct to epinephrine and other standard measures for the acute symptoms of anaphylaxis. • Antihistamine overdose reactions may vary from central nervous system depression to stimulation. • Use extreme caution when administering to patients who have ingested alcohol and other depressant drugs. Revision Date 02/28/2011 414 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference CARDIZEM MED REF Page 415 TOC Medication Calcium channel blocker Mechanism of Action Diltiazem inhibits the influx of Ca+ ions during membrane depolarization of cardiac and vascular smooth muscle. Diltiazem slows the ventricular rate in patients with a rapid ventricular response during A-Fib or A-Flutter. The therapeutic benefits of Diltiazem in supraventricular tachycardias are related to its ability to slow AV nodal conduction time and prolong AV nodal refractoriness. Indications • Narrow-complex tachycardia refractory to Adenosine • A-Fib/A-Flutter with RVR (>150 bpm) Contraindications • Ventricular tachycardia or any wide QRS of uncertain origin. • Known hypersensitivity • Patient with sick sinus syndrome except in the presence of a functioning ventricular pacemaker. • Patients with 2nd or 3rd degree AV block. • Any patient who has received IV beta blockers within the last few hours. • Patients with A-Fib or A-Flutter associated with WPW and short PR syndrome. • Contraindicated in newborns. Side Effects • 2nd or 3rd degree AV block • Hypotension • Nausea • Vomiting • Dizziness Dosage and Administration • ADULT: Diltiazem 10 – 20 mg IV - Followed by 80 – 90 mg infusion at 5 mg/hr Special Considerations Patient may experience burning or itching at the injection site. Revision Date 05/21/2007 415 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference AMIODARONE MED REF Page 416 TOC (Amiodarone Hyrdochloride) Medication Amiodarone is classified as a Class III anti-arrhythmic but has characteristics of all 4 anti-arrhythmic classes. Mechanism of Action • Amiodarone has a rapid onset. • Acts directly on the cardiac cell membrane by blocking sodium channels. • Prolongs repolarization and refractory period. • Increases ventricular fibrillation threshold • Acts on peripheral smooth muscle to ↓ peripheral resistance. Indications • Ventricular Fibrillation • Hemo-dynamically unstable Ventricular Tachycardia • Narrow Complex Tachycardia Contraindications • Use in caution with patients with Hypokalemia and Hypomagnesemia. • Heart Block or severe Bradycardia Side Effects • Hypotension • Bradycardia • Nausea Revision Date 03/29/2006 • • Watch for QT prolongation May worsen the arrhythmia or precipitate new arrhythmias. 416 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference AMIODARONE MED REF Page 417 TOC Dosage and Administration ADULT: • • • • • Ventricular Fibrillation: Ventricular Tachycardia Unstable: Ventricular Tachycardia Stable: Ventricular Ectopy: Post-Resuscitation Management: 300 mg IV Bolus can repeat once at 150mg after 10 minutes. 150 mg IV Loading dose 150 mg IV Loading dose 150 mg IV Loading dose 1 mg/min IV infusion Loading Dose • Mix 150 mg Amiodarone into 100 ml NS, infuse over 10 min via infusion pump Initiating an Infusion: • Mix 150 mg Amiodarone into 100 ml NS, Run infusion at 1 mg/min • The infusion should be started within 20 min after the resolution of the arrhythmia. PEDIATRIC: • Ventricular Fibrillation 5 mg/kg bolus Special Considerations Drugs whose effects may be increased by Amiodarone: • Propranolol - Beta Blocker • Verapamil - Calcium Channel Blocker • Diltiazem Calcium Channel Blocker Drugs whose effects may increase side effects of Amiodarone • Bretylium Hypotension • MS Hypotension • Fentanyl Hypotension and Bradycardia Other Drug to Drug interactions: • Dilantin Decreases serum blood levels of Amiodarone. • Cimetidine - Increases serum blood levels Amiodarone. • Digitalis Digitalis toxicity Revision Date 03/29/2006 417 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference CALCIUM GLUCONATE MED REF Page 418 TOC Medication Calcium Gluconate is a cation electrolyte. Mechanism of Action Needed for the maintenance of nervous, muscular, skeletal, enzymatic reactions, normal cardiac contractility, blood coagulation, and several other physiological activities. Indications • Magnesium sulfate or Calcium Channel blocker overdose. • May be helpful in relieving specific muscle spasms due to hypocalcemia. • Cardiac Arrest in a renal dialysis patients. • Arrhythmias and /or cardiac toxicity due to hyperkalemia. • May be helpful for relief of pain and muscle spasms due to black widow spider bite. Contraindications Calcium Gluconate should be given with extreme caution and in reduced dosage in the following settings: • • • Patient’s taking Digitalis Hypercalcemia VFib • • • Renal Calculi (Kidney Stones) CHF Patients with pre-existing renal disease. Side Effects • Hypercalcemia • N/V and Diarrhea • Lethargy/Drowsiness • Headache • May ↑ myocardial irritability in the presence of digitalis. Dosage & Administration ADULT: 4.65 mEq/10ml (10% solution) SLOW IV PEDIATRIC: No Protocol Special Considerations • Calcium Gluconate is administered intravenously only. It should not be administered IM or SQ • Cause tissue irritation and necrosis if infiltrated • Precipitates when mixed with sodium bicarbonate. Revision Date 11/01/2005 418 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference DECADRON MED REF Page 419 TOC (Dexamethasone) Medication Decadron, is functionally a corticosteroid medication, is used principally to treat severe allergic reaction, respiratory distress, and as prophylaxis in patients who already take steroids, or are dependant on steroids, and are experiencing a stressful event. Mechanism of Action Decadron inhibits inflammatory response of tissues due to mechanical, chemical, infectious, inflammatory, or other causes, preserves the integrity of small blood vessels in shock states, increase cardiac output, and stabilizes cellular membranes. Decadron is metabolized by the liver and excreted by the kidney. Indications • Life threatening shock states • Bronchial asthma and other bronchospastic states unresponsive to conventional treatment. Contraindications • Myasthenia Gravis. • Thromboembolic disease. • Renal insufficiency. • Use with caution if the patient has a history of diabetes mellitus Side Effects • N/V and Diarrhea • CNS depression • Weakness • Aggravation of diabetes mellitus Dosage & Administration Dosage should be based on the size of the patient: ADULT: 10 mg IV/IM/IO PEDIATRIC: 0.2–0.5 mg/kg IV/IM/IO Special Considerations • Neurological findings may be affected by the administration of Decadron. Documentation of neurological status is essential prior to administering Decadron in that subsequent neurologic evaluation is made more difficult after administration of the medication. • Sensitive to extremes in temperature so store to protect from freezing or excess heat. Revision Date 11/01/2005 419 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference DEXTROSE (25%-50%) MED REF Page 420 TOC Medication A simple sugar of the monosacharose group, dextrose occurs naturally in plants and in the body fluids of animals. It is formed in the digestive tract by the action of enzymes on carbohydrates. It is packaged as a hypertonic dextrose solution. Mechanism of Action The administration of Dextrose raises circulating blood sugar levels. It also acts transiently as a diuretic. Dextrose (glucose) is the main energy source for the body’s cells especially the brain. Onset: IV: 30 – 60 seconds Indications • Hypoglycemia • Unconsciousness of unknown origin, without S/S of head injury • Seizure of unknown origin, without S/S of head injury Contraindications D50% should not be administered to any patient presenting with S/S of central nervous system pathology. • • • Intracranial Hemorrhage Cerebral Edema ↑ ICP Side Effects • Tissue necrosis due to infiltration • Administration of dextrose may precipitate severe neurologic symptoms in the alcoholic patient. • Hyperglycemia / hyperosmolality. Dosage & Administration It is important that blood be drawn (red & purple tops) prior to the administration of Dextrose and that a patent vascular access has been established. ADULT: 25 grams IV (50 ml of D50) PEDIATRICS: 0.5 g/kg - > 10kg or 2 years of age: 1 ml/kg of 50% - < 10kg: 2 ml/kg of 25% Revision Date 11/01/2005 420 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference DEXTROSE (25%-50%) MED REF Page 421 TOC Special Considerations • Dextrose is a relatively thick solution and is more easily administered through a large bore catheter. • Administration of dextrose may precipitate severe neurologic symptoms in the alcoholic patient. Thiamine should be administered prior to Dextrose in patients presenting with possible alcohol abuse. • If level of consciousness increases, ensure patient eats. Revision Date 11/01/2005 421 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference DOPAMINE HCL MED REF Page 422 TOC (Intropin) Medication A catecholamine synthesized by the adrenal gland, dopamine is the immediate precursor in the synthesis of norepinephrine. Mechanism of Action Dopamine acts as a β sympathetic mediator causing an ↑ in the force and rate of cardiac contractions as well as dilatation of renal and mesenteric arteries. • Dopamine exerts an inotropic effect on the myocardium resulting in a ↑ cardiac output. Dopamine usually ↑ systolic and pulse pressure with either no effect or a slight ↑ in diastolic pressure. • Dopamine does not significantly ↑ myocardial O2 consumption. • Dopamine dilates renal vasculature presumptively by activation of a dopaminergic receptor, causing an ↑ glomerular filtration rate, renal blood flow and sodium excretion ( ↑ urinary output ) • Action of this medication is dependent on the dosage level: 1. Low dosages: - β effects predominate (1–2 µg/kg/min) - ↑ Myocardial contractility 2. Moderate dosages: - ↑ Cardiac Output (2–10 µg/kg/min) - Dilation of renal and mesenteric arteries. 3. Mod. high dosages: - ↑ B/P 10–20 µg/kg/min) - Peripheral vasoconstriction 4. High dosages: - α effect reverses dilation of renal and (> 20 µg/kg/min) mesenteric vessels. - ↓ Flow through these vessels. Indications • Hypotension during non-hypovolemic shock states. • Symptomatic bradycardia when refractory to Atropine and external pacing. Contraindications • Dopamine should not be administered in the presence of uncorrected tachyarrhythmias or VFib. • Serious acute hypertension may develop in patients with pheochromocytoma (a tumor that produces epinephrine and/or related substances) Revision Date 11/01/2005 422 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference DOPAMINE HCL MED REF Page 423 TOC Side Effects • Ectopic Beats, Palpitations, Tachycardia • N/V • Dyspnea • Angina • Headache Dosage & Administration ADULT: Administer 5–10 µg/kg/min via IV infusion using a microdrip set. Titrating the infusion to effect on level of consciousness and B/P If Pre-mix unavailable: • Add 800mg dopamine to 1000ml of NS 0.9% - Yielding a concentration of 800 µg/ml. Special Considerations • • • • Dopamine ↑ contractility of the myocardium and may be detrimental in patients with severe myocardial ischemia. Do not mix with sodium bicarbonate since dopamine may be inactivated by alkaline solutions. The effects of dopamine may be potentiated by medications such as Parnate, Marplan, and Nardil. Serious acute hypertension may develop in patients with pheochromocytoma (a tumor that produces epinephrine and/or related substances) Revision Date 11/01/2005 423 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference EPINEPHRINE HCL MED REF Page 424 TOC (Adrenaline) Medication Epinephrine is an endogenous (hormone) catecholamine with nonselective β1, β2, and α properties. It is an adrenergic (sympathomimetic) agent and cardiac stimulant; It is Secreted by the medulla of the adrenal gland. Mechanism of Action • Epinephrine stimulates alpha-1, beta-1, and beta2-adrenergic receptors in doserelated fashion. The most prominent actions are on the β receptors of the heart, vasculature, and other smooth muscles. • Rapid injection produces a rapid increase in systolic pressure, ventricular contractility, and heart rate: • The β1 sympathetic actions of epinephrine causes: 1. Increased rate of sinus node 2. Increased myocardial contractility 3. Increased AV conduction 4. Increased myocardial irritability • The β2 sympathetic action causes bronchodilation and vasodilation. • The αeffect of epinephrine causes vasoconstriction in the arterioles of the skin, mucosa, and splanchnic areas to: 1. ↑ the perfusion pressure and possibly improving coronary blood flow. 2. Antagonize the effects of histamine. Indications • Anaphylaxis / Acute allergic reaction • Asthma • The treatment and prophylaxis of cardiac arrest to: 1. Restore electrical activity in asystole 2. Enhance defibrillation potential in VFib 3. Elevate SVR and ↑ perfusion pressure during resuscitative efforts. • Bradyarrhythmias resistant to Atropine. Contraindications • No contraindications in cardiac arrest or anaphylactic shock. • Hypersensitivity (only on pulsing patients) • Hypovolemic shock • Use with caution in: 1. Hypertensive states 2. Ischemic Heart Disease / Coronary insufficiency 3. Obstetrical patient with B/P > 120/80 mmHg 4. In patients receiving Isoproterenol, digitalis, and/or other sympathomimetics. Revision Date 03/28/2011 424 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference EPINEPHRINE HCL MED REF Side Effects • Arrhythmia’s / Tachycardias • Palpitations / Ectopic beats • Precipitation of anginal pain • • • Page 425 TOC ↑ B/P Anxiety Restlessness / tremors Dosage & Administration • • 1:10,000 contains: 1:1,000 contains: 0.1 mg/ml 1 mg/ml ADULT: • Cardiac Arrest: • Allergic Reaction: 0.3 mg IM (1:1,000) • Anaphylaxis: 0.5 mg IV/IO (1:10,000) 0.5 mg SL (1:1,000) • Bronchospasm: 0.3 mg IM (1:1,000) 1 mg IV/IO / 2 mg ET q 3–5 min. - unconscious - vascular collapse PEDIATRIC: • Cardiac Arrest: • Allergic Reaction: 0.01 mg/kg IM (1:1,000) • Anaphylaxis: 0.01 mg/kg IV/IO (1:10,000) 0.01mg /kg SL (1:1,000) • Bronchospasm: 0.01 mg/kg IM (1:1,000) 0.01 mg/kg IV/IO (0.1 ml/kg1: 10,000) q 3–5 min. 0.1 mg/kg ET (1:1,000) INFUSION: PEDIATRICS: To mix Epinephrine infusion: - 0.6 multiplied by the child’s weight in kg. This amount (in mg) is then added to enough IV solution to equal a total volume of 100 ml. - Infuse at 20 ml/hr via infusion pump until clinical response (increased heart rate OR blood pressure OR improved systemic perfusion) Reduce infusion to 0.1 to 1 mcg/kg/minute with Baxter Pump - 1 ml/hr equals 1 mcg/kg/minute Revision Date 03/28/2011 425 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference EPINEPHRINE HCL MED REF Page 426 TOC Special Considerations • In cases of shock, administer epinephrine via the IV route rather than the subcutaneous route due to the poor perfusion. • MAOI’s may potentiate the effect of epinephrine. • Beta-adrenergic antagonists may blunt inotropic response. • May be deactivated by alkaline solution (sodium bicarbonate). Revision Date 03/28/2011 426 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference ETOMIDATE MED REF Page 427 TOC (Amidate) Medication Etomidate is a non-barbiturate hypnotic without analgesic properties. In therapeutic doses, Etomidate has minimal effect on myocardial metabolism, cardiac output, and peripheral or pulmonary circulation. Mechanism of Action Etomidate is a sedative-hypnotic used to induce anesthesia that should last approximately 3–10 minutes. Indications Induction of anesthesia prior to administration of a neuromuscular blockade Contraindications None when used as indicated Side Effects • Hypotension, arrthymias, hypertension • Hyperventilation, hypoventilation, laryngospasm • Myoclonus, tonic movement, eye movements • Nausea/Vomiting Dosage and Administration ADULT: 20 mg IV PEDIATRIC: No protocol Special Considerations • Use with caution in patients with focal epilepsy • Injection into small veins can cause pain • Myoclonus is reduced by pre-medicating with Diazepam Revision Date 11/01/2005 427 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference FENTANYL MED REF Page 428 TOC (Sublimaze) Medication A potent synthetic opiate with analgesic properties. In therapeutic doses, Fentanyl has little effect on hemodynamic compromise, and may be useful in those with borderline hypotension or heart failure. Mechanism of Action • • • Inhibits ascending pain pathways primarily through interaction with opioid µ receptors located in the brain, spinal cord and smooth muscle. Drug alters perception of pain and emotional response to pain. When administered in high doses it may produce loss of consciousness. Indications For control of moderate to severe pain related to: • • • • Musculo-skeletal disorders Burns Amputations Abdominal pain indicative of kidney stones. Contraindications Hypersensitivity to drug Side Effects • Bradycardia • Apnea, Hypoventilation • Headache, Dizziness, Sedation • Nausea/Vomiting, Constipation Dosage and Administration ADULT: 0.5 - 1 mcg/kg SLOW IV/IO, FAST IN prn Pain management ο Maximum Single Dose 100 mcg ο Titrate to 30-50% reduction in pain ο May repeat q 5 minutes prn 100 mcg SLOW IV/IO, FAST IN RSI PEDIATRIC: 0.5 mcg/kg SLOW IV/IO, FAST IN 2 mcg/kg SLOW IV/IO, FAST IN Pain management RSI Special Considerations • Use with caution in elderly, young or debilitated patients • Use with caution in patients with respiratory or hepatic dysfunction • May interfere with neurological assessment in patients with head injury • Not for routine administration for generalized abdominal pain Revision Date 06/10/2009 428 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference GLUCAGON MED REF Page 429 TOC Medication A pancreatic hormone-insulin antagonist Mechanism of Action • Causes breakdown of glycogen to glucose • Inhibits glycogen synthesis • Elevates blood glucose levels • Increases cardiac contractile force • Increases heart rate Indications • Altered LOC where hypoglycemia is suspected and an IV route is not immediately available • Beta blocker overdose • Calcium channel blocker overdose Contraindications • Hypersensitivity to drug • Allergy to proteins Side Effects • Tachycardia • Hypertension • Nausea/vomiting • Allergic reaction Dosage & Administration ADULT: 1 mg IM may repeat in 20 min. PEDIATRIC: 0.5 mg IM/SQ may repeat in 20 min. Special Considerations Revision Date 03/29/2006 429 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference IBUPROFEN MED REF Page 430 TOC (Motrin) Medication Nonsteroidal anti-inflammatory drug (NSAID) with significant antipyretic and analgesic properties. Mechanism of Action Blocks prostaglandin synthesis, inhibits platelet aggregation, and prolongs bleeding time, but does not affect prothrombin or whole blood clotting times. Indications Fever Contraindications • Hypersensitivity to Aspirin or other NSAIDs • Active peptic ulcer disease • Bleeding abnormalities • Severe renal disease • Severe hepatic disease • < 6 months of age Side Effects • Anxiety, confusion, depression, dizziness, drowsiness, fatigue, insomnia, tremors • CHF, dysrhythmias, HTN, palpitations, peripheral edema, tachycardia • Blurred vision, hearing loss, tinnitus • Constipation, cramps, diarrhea, dry mouth, flatulence, GI hemorrhage, jaundice, nausea/vomiting, peptic ulcer • Azotemia, hematuria, nephrotoxicity, oliguria • Ιncreased bleeding time • Pruritus, purpura, rash, sweating Dosage & Administration Age 6–11 mo 12–23 mo 2–3 yrs 4–5 yrs 6–8 yrs 9–10 yrs 11 yrs Revision Date 02/28/2011 Weight (lbs) 12–17 18–23 24–35 36–47 48–59 60–71 72–95 Dose 50 mg/ 2.5ml 80 mg/ 4ml 110 mg/ 5.5ml 160 mg/ 8ml 220 mg/ 11ml 270 mg/ 13.5ml 325 mg/ 16.25ml 430 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference IBUPROFEN MED REF Page 431 TOC Special Considerations • Patients with history of cardiac decompensation should be observed closely for evidence of fluid retention and edema. • Monitor for GI distress and signs of GI hemorrhage. • Symptoms of acute toxicity in children are apnea, cyanosis, response only to painful stimuli, dizziness and nystagmus. Revision Date 02/28/2011 431 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference KETAMINE MED REF Page 432 TOC Ketamine Hydrochloride (Ketalar) Medication Ketamine is a central nervous system agent that produces a rapid-acting dissociative effect and has limited cardiovascular or respiratory side effects. Ketamine is unique for its ability to provide anxiolysis, analgesia, and amnesia safely and simultaneously. Analgesia provided by Ketamine is roughly double that provided by morphine Amnesia induced by Ketamine is on the same order as that induced by Midazolam Mechanism of Action Ketamine has a direct action on the cortex and limbic system and produces a cataleptic-like state that separates the mid-brain from cortical input. Lower brain control of vital functions is stimulated by Ketamine. Occupation of opiate receptors produce pain relief. Ketamine promotes gastric motility. Vomiting after administration is unusual. Indications Rapid control of the violent or agitated patient requiring medical intervention and transport. Sedation and analgesia of the critical Trauma or Medical patient requiring intubation and mechanical ventilation Contraindications Absolute: Control of patient parameters by other less invasive means Relative: Hypertensive crisis / Angina Signs of significant elevated intracranial pressure Inability to support or control airway Side Effects Common: Blurred vision Increased blood pressure Increased heart rate Severe: Laryngospasm Emergence reactions Nausea Increased Oral secretions Apnea Dosage & Administration Adult/Pedi: 1-2 mg/kg IV or 2-4 mg/kg IM for control of violent/agitated patient Adult/Pedi: 1-2 mg/kg IV (over 60 seconds) for RSI / post intubation sedation Special Considerations The administration of benzodiazepines (Midazolam) or Promethazine (Promethazine) during the emergence phase of Ketamine can prevent/lessen unpleasant reactions. Revision Date 02/28/2011 432 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference LABETALOL MED REF Page 433 TOC (Normadyne, Trandate) Medication Labetalol is a competitive alpha1-receptor blocker as well as a nonselective betareceptor blocker used to lower blood pressure in a hypertensive crisis. Mechanism of Action The beta1 blocking actions on the S.A. node, A.V. node and ventricular muscle cause negative chronotropic, dromotropic and inotropic effects. The beta2 blocking actions cause bronchoconstriction. The alpha blocking actions lead to general vasodilation and reduced P.V.R. The net C.V. effects are a decrease in B/P without reflex tachycardia or significant reduction in H.R. Indications • Systolic B/P >200 or a Diastolic B/P >110 with or without S/S • Hypertensive Crisis (Systolic B/P >200 or a Diastolic B/P >110) Contraindications Absolute: • STEMI precipitated by cocaine use • Heart block Relative: • Heart Rate <60 bpm • Systolic Blood Pressure <100 mmHg • Active CHF • Active Asthma Side Effects • Postural hypotension • Fever • Liver toxicity • Exacerbates CHF • • • • Exacerbates bronchospasm Wheezing, dyspnea Fatigue Depression Dosage & Administration ADULT: PEDIATRIC: 10 mg intravenously over 1 to 2 minutes Not recommended Special Considerations • Use with extreme caution as severe decreases in B/P can occur. • Increased hypotensive effect with Cimetidine and calcium channel blockers • Labetalol may blunt bronchodilator effects of beta-adrenergic agonists. • Nitroglycerin may augment hypotensive effects. • Decreased effect and possible hypertensive crisis with NSAIDS. Revision Date 05/21/2007 433 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference • LABETALOL MED REF Page 434 TOC There are some situations in which sympathetic stimulation is vital. For example, patients with severely damaged hearts may depend on the sympathetic drive to reach adequate ventricular function. This medication could block this drive and precipitate heart failure. Revision Date 05/21/2007 434 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference LIDOCAINE HCL MED REF Page 435 TOC (Xylocaine) Medication Lidocaine is classified as a Class IV antiarrhythmic and a local anesthetic that is used intravenously to treat certain ventricular arrhythmias. Mechanism of Action Lidocaine suppresses dysrhythmias of ectopic ventricular origin and in ischemic tissue by ↓ the automaticity of ventricular pacemaker cells and the conduction system. Lidocaine elevates ventricular fibrillation threshold. Reduces non-uniformity of repolarization in the purkinje fibers and altars conduction velocity in these fibers to abolish re-entrant ventricular dysrhythmias and unidirectional ventricular tachycardia. Lidocaine has only minimal effects on atrial muscle. Indications • PVC’s when they: 1. occur in the context of myocardial ischemia (chest pain) 2. occur > 6/min. 3. occur in salvos (2 or more) 4. fall close to the T wave 5. Multifocal • VFib/ VTach • To prevent the recurrence of VFib or VTach after conversion Contraindications • Known hypersensitivity to “amides” or “caine” medications. • Sinus bradycardia, 2° or 3° heart block, or Idioventricular rhythm • Wolff-Parkinson-White syndrome (Lidocaine may block aberrant pathway). • Stokes - Adams syndrome (transient heart block with syncope). Side Effects • May cause a fall in cardiac output and B/P. • May cause seizure-like activity when given in high doses. • May also cause tremors, lethargy, muscle twitching, and/or coma. • Clinical indicators of toxicity: Drowsiness decreased hearing ability, paresthesias, muscle twitching, seizures, bradycardia or heart block. Revision Date 11/01/2005 435 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference LIDOCAINE HCL MED REF Page 436 TOC Dosage & Administration ADULT: Initial: 1–1.5 mg/kg IV (2–3 mg/kg ET) Subsequent: 0.5 mg/kg IV (1 – 1.5 mg/kg ET) Max: 3 mg/kg Adult Infusion: 2 – 4 mg/min. PEDIATRIC: 1 mg/kg IV (2 mg/kg ET) Pediatric Lidocaine Infusion Dose: 20 – 50µg/kg/min Preparation: 100 mg lidocaine in 100 ml NS Dosage: 20 µg/kg/min 30 µg/kg/min 40 µg/kg/min 50 µg/kg/min 6 drops/min per 5 kg 9 drops/min per 5 kg 12 drops/min per 5 kg 15 drops/min per 5 kg Special Considerations • Reduction of dosage should be considered in patients >70 y/o, patients presenting with ↓ cardiac output (CHF, shock), or liver disease. Revision Date 11/01/2005 436 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference MAGNESIUM SULFATE MED REF Page 437 TOC Medication Magnesium Sulfate is an electrolyte salt solution with C.N.S. depressant-like properties. Mechanism of Action Magnesium is a cofactor in numerous enzymatic reactions and is essential for the function of the sodium-potassium ATPase pump. It acts as a physiological calcium channel blocker and blocks neuromuscular transmission of acetylcholine. Magnesium is also a potent peripheral vasodilator and increases the fibrillation threshold. Indications • Refractory VFib or VTach • Torsade-de-Pointes • Seizures accompanying eclampsia (Toxemia of pregnancy) • Bronchospasm Contraindications High degree AV block Side Effects • Hypotension, circulatory collapse, heart block • Respiratory depression or paralysis • Flaccid paralysis, depressed reflexes • Hypocalcemia • Flushing, sweating, hypothermia Dosage & Administration ADULT: PEDIATRIC: 1–2 grams IV/IO Infusion: Mix 1 gram in 100 ml NS infused via pump over 10 minutes 25–50 mg/kg IV/IO (max. 2g) Special Considerations • Side effects are usually from administering too rapidly. • Assess deep tendon reflexes (D.T.R.s) before, during and after administration • If depressed cardiac function, respiration rate below 12/minute or no reflex activity is noted consider the administration of Calcium Gluconate 500 mg IV (up to 1 gm) until untoward side effects are abolished Revision Date 11/01/2005 437 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference METOPROLOL MED REF Page 438 TOC Metoprolol (Lopressor) Medication Metoprolol is a Beta1 selective blocker used decrease the automaticity of cardiac contractions. Mechanism of Action Competitively blocks beta-adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and heart rate. Thus the workload and oxygen demand of the heart is reduced. Metoprolol does not produce coronary vasodilatation but leads to a shift and redistribution of coronary circulation to the ischemic areas, thereby decreasing the release of renin from the kidney, thus lowering blood pressure. Additionally, it acts in the CNS to reduce sympathetic outflow and vasoconstrictor tone. Indications • Acute Coronary Syndrome • Cardiac Ischemia • STEMI Contraindications Absolute: • Heart Rate <60 bpm • Systolic Blood Pressure <100 mmHg • 2nd and 3rd degree heart block • 1st degree heart block with PR interval > 0.24 sec • STEMI precipitated by cocaine use Relative: • Pregnancy-2nd and 3rd trimester • Cardiogenic shock • Active CHF • Active Asthma • COPD Side Effects • Bradycardia • Heart Block • hypotension • Exacerbates CHF • Headache • • • • • Exacerbates bronchospasm Dyspnea Dizziness Fatigue Depression Dosage & Administration ADULT: 5 mg IV/IO q5 min up to 3 doses (15 mg) PEDIATRIC: Not recommended Special Considerations None Revision Date 05/21/2007 438 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference NARCAN MED REF Page 439 TOC (Naloxone) Medication Naloxone is a synthetic opioid antagonist that inhibits the analgesic effects of opiates. It is used in the management and reversal of overdoses caused by narcotics and synthetic narcotic agents Mechanism of Action Naloxone antagonizes the opioid effects by competing for the same receptor sites. Naloxone should reverse stupor, coma, and respiratory depression when administered to patients who have ingested narcotic drugs. May precipitate withdrawal symptoms in patients dependent on narcotics. Some frequently used narcotics include: • Heroin • Codeine • Darvon • Stadol • Morphine • Demerol • Percodan • Talwin • Methadone • Dilaudid • Fentanyl Indications • Known narcotic overdose • Unconsciousness of unknown etiology Contraindications • Hypersensitivity • Use with caution in narcotic-dependent patients who may experience withdrawal syndrome (including neonates of narcotic- dependent mothers) Side Effects • Nausea • Rapid administration may precipitate projectile vomiting • Severe withdrawal symptoms in the addicted patient Dosage & Administration ADULT: 0.4 mg – 2 mg SLOW IV, IM, IO FAST IN q 10–15 min if response seen PEDIATRIC: 0.1 mg/kg SLOW IV, IM, IO FAST IN (Max: 2 mg single dose) Special Considerations • Since most narcotics have longer duration of action, repeated doses of Naloxone may be required. • The patient who has satisfactorily responded to Naloxone should be kept under continued surveillance and repeated doses should be administered as necessary since the duration of action of some narcotics exceed that of Naloxone. Revision Date 02/28/2011 439 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference NITROGLYCERIN MED REF Page 440 TOC (Nitrostat, Nitrolingual Spray) Medication Nitroglycerin (NTG), an organic nitrate, is a smooth muscle vasodilating agent. Mechanism of Action The mechanism by which NTG produces relaxation of smooth muscle is unknown. Although venous effects predominate, NTG produces, in a dose-related manner, dilation of both arterial and venous beds. • Dilation of the post capillary vessels, including large veins, promotes peripheral pooling of blood and ↓ venous return to the heart, ↓ left ventricular end-diastolic pressure (preload). • Arteriolar relaxation reduces systemic vascular resistance and arterial pressure (afterload). • Myocardial O2 consumption or demand is ↓ by both the arterial and venous effects of NTG, creating a more favorable supply-demand ratio. Indication • • Ischemic chest pain Congestive heart failure Contraindications NTG should be used with extreme caution in patients presenting with: • Hypersensitivity • ICP /Head injury • Hypotension • Nitroglycerin, in any form, is not to be administered to patients that have taken Viagra (Sildenafil citrate) or Levitra (Vardenafil HCl) within the last 24 hours. • Nitroglycerin is not to be administered to patients who have taken Cialis (Tadalafil) within the last 48 hours. • Fatal hypotension has been reported when Nitroglycerin or other Nitrates are given to patients who have used Viagra or Levitra in last 24 hours, and in patients who have used Cialis in the last 48 hours. Side Effects • Throbbing Headache (means it’s working) • N/V • Hypotension / Postural Hypotension • • • Palpitations Weakness Vertigo Dosage & Administration ADULT: 0.4 mg SL or MDI q 5 min prn. if systolic B.P. is > than 100 mmHg 0.8 mg SL for CHF 1” Paste PEDIATRIC: Not recommended Special Considerations • Administer to patients sitting or semi-reclined Revision Date 03/29/2006 440 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference • • • • • NITROGLYCERIN MED REF Page 441 TOC Excessive use may lead to the development of tolerance. B/P should be monitored closely. Other vasodilators may have additive hypotensive effects (Viagra or similar medication). Nitroglycerin decomposes when exposed to light or heat. Loses potency after prolonged storage. Replace stock every 4 – 6 months - label a newly opened bottle with the date. Revision Date 03/29/2006 441 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference NITROUS OXIDE MED REF Page 442 TOC (Nitronox) Medication Nitrous oxide is colorless, odorless and tasteless anesthetic gas that, when mixed with oxygen, acts to relieve pain. Mechanism of Action Nitrous oxide is absorbed through the alveoli by inhalation. It depresses the central nervous system and relieves pain. Inhalation of 20% nitrous oxide has been compared to 15 mg of Morphine. Nitrogen does not bind with the hemoglobin and is carried in the plasma. Because of its slow diffusion across membranes, it occupies the gas filled spaces in the body Indications Mild to moderate pain due to any of the following: • Isolated Musculo-Skeletal injuries • Burns • Renal Calculi (Kidney Stones) Contraindications • Altered mentation • Alcohol or Drug Intoxication • Head injury with altered mental status • COPD • Pneumothorax / Chest injuries Side Effects • Headache • Dizziness, drowsiness • N/V Dosage & Administration ADULT & PEDIATRIC: Self-administered inhalation (50% N2O / 50% O2) Special Considerations • Use in well ventilated areas. • If side effects occur, discontinue inhalation therapy and apply 100% oxygen for at least 5 minutes. Revision Date 11/01/2005 442 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference NORMAL SALINE MED REF Page 443 TOC (0.9% Sodium Chloride - Intravenous Solution) Medication Isotonic crystalloid salt solution used for intravenous infusion and intravenous medium. Mechanism of Action • Expands circulating volume by approximating sodium content of the blood. Sodium Chloride passes out of the blood stream quite rapidly, especially when normal renal function and renal blood flow are present. • Each liter provides 154 mEq of sodium and 154 mEq of chloride. Indications • Used to maintain a patent Intravenous access • Used in hypovolemic and/or dehydration states for any reason. • Used to facilitate the excretion of thick mucous plugs from the lungs. • Used for dilution of medications and/or as a flushing agent for rapid IV medication administration. • Used as an irrigation solution for eyes and wounds Contraindications Use with caution with CHF Side Effects • Fluid overload / Edema • Electrolyte imbalance • Hypertension Dosage & Administration ADULT: TKO for general access, IV fluid bolus 250 – 500 cc for rapid administration and fluid resuscitation PEDIATRIC: TKO for general access 20 ml/kg IV or IO, infused rapidly, for fluid resuscitation Special Considerations • Reassess and repeat fluid bolus if poor perfusion is observed • Frequently auscultate breath sounds frequently for rales. Revision Date 11/01/2005 443 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference OXYGEN MED REF Page 444 TOC Medication An element – utilized as the primary energy source for the development and maintenance of life. Required by most cellular activities in order to maintain the homeostasis within the body. Mechanism of Action Oxygen is utilized in all cellular activity occurring within the body, such as metabolism. When cellular functions occur in a hypoxic or anoxic state the cells utilize other sources of energy, such as fat. This causes an accumulation of harmful by-products (lactic acid) which may lead to certain death if not corrected. Indications • At the discretion of the EMS personnel • Treat and prevent hypoxemia • Decrease myocardial work and respiratory effort. • Any major illness or injury. • Saturations below 95% • Saturations below 85% indicate the need for ventilatory assistance and oxygen therapy. Contraindications None for short term emergency use Side Effects None for short term emergency use Dosage & Administration Pulse oximetry and other clinical indicators should determine therapy. • • • • Nasal cannula: 1 – 6 L.P.M. (provides 24 - 44% oxygen). Simple mask: 6 –10 L.P.M. (provides 40 - 60% oxygen). Non-rebreather mask: 10 – 15 L.P.M. (provides >90% oxygen). Bag-valve-mask: 15 L.P.M. with reservoir (provides >90% oxygen). Special Considerations • Humidifying oxygen using low flow devices such as nasal cannulas should prevent drying of nasal and pulmonary mucosa. • Do not withhold oxygen from a COPD patient if he/she needs it. Initially try low flows via nasal cannula but, if more is needed, supply it and carefully monitor ventilations. Revision Date 11/01/2005 444 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference PROMETHAZINE MED REF Page 445 TOC (Promethazine) Medication Promethazine is a phenothiazine with sedative, antiemetic, antihistamine and anticholinergic properties Mechanism of Action It competitively blocks histamine (H1) receptors. It does not block the release of histamine. The central anti-muscurinic actions of antihistamines are probably responsible for the antiemetic and anti-vertigo effects. Reducing stimuli to the brainstem reticular system probably causes the C.N.S. sedation. Additionally, Promethazine potentiates the effects of narcotics. Indications Nausea/ Vomiting Contraindications • Hypersensitivity • Altered Mental Status • Hypotension • Large ingestion of sedatives • Use with caution with asthma patients (thickens mucous). • Use with caution with patients who have a history of Epilepsy (may trigger seizure) Side Effects • May cause sedation, confusion, or restlessness • Hypotension and hypertension • Extrapyramidal reactions (dystonia) • Urinary retention Dosage & Administration ADULT: 12.5 to 25 mg IV/IO/IM (IV/IO only dilute in 10 ml over 1–-2 minutes.) PEDIATRICS: 0.5 mg/kg IV/IO/IM, up to 12.5mg (IV/IO only dilute in 10 ml over 1–2 minutes) Special Considerations Extrapyramidal side effects generally responds to Diphenhydramine administration Revision Date 11/01/2005 445 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference RETAVASE MED REF Page 446 TOC (Reteplase) Medication Fibrinolytic Mechanism of Action Catalyzes the cleavage of endogenous plasminogen to generate plasmin; plasmin degrades the fibrin matrix of an offending thrombus - fibrinolysis Indications Management of acute myocardial infarction Contraindications • Active internal hemorrhage • History of CVA • Recent intracranial or intraspinal surgery or trauma • Intracranial neoplasm, arteriovenous malformation, or aneurysm • Known bleeding diathesis • Severe uncontrolled hypertension Side Effects • Bleeding • Dysrhythmias • • • • • • • Allergic reaction Reinfarction Tamponade Nausea/Vomiting Fever Hypotension Dosage & Administration 10 units SIV – repeat dose in 30 minutes Special Considerations • Use the sterile water packaged with the Retavase for reconstitution. This sterile water has no preservatives. • No other medications should be administered through the same line. Revision Date 11/01/2005 446 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference SODIUM BICARBONATE MED REF Page 447 TOC Medication Sodium bicarbonate is a hypertonic solution used as a systemic alkalizer (buffer). In water, it dissociates to provide sodium (Na+) and bicarbonate (HCO3-) ions. • Sodium is the principal cation of the extracellular fluid and plays a large part in the therapy of fluid and electrolyte disturbances. • Bicarbonate is a normal constituent of body fluids. Mechanism of Action • Reacts with hydrogen ions to form water and carbon dioxide and thereby can act to buffer metabolic acidosis. • It corrects metabolic acidosis by neutralizing excess acid in the blood, helping to return the blood towards a physiologic pH, in which metabolic processes and sympathomimetic agents work more efficiently. • Increasing the plasma concentration of bicarbonate causes blood pH to rise. • In tricyclic antidepressant overdose, alkalization of serum pH increases protein binding of TCA’s, this significantly lessens the potential for toxicity. • Produces paradoxical acidosis due to the production of carbon dioxide, which is freely diffusible into myocardial and cerebral cells. Indications • Cardiac arrest situations with a down time > 10 min and the patient is intubated. • TCA overdose (ECG: QRS complex widening by 50%). • Known preexisting bicarbonate-responsive acidosis Contraindications • No contraindications when used for indicated life-threatening emergencies • CHF - cannot tolerate a salt load • Metabolic and respiratory alkalosis • Use with caution in the dehydrated patient due to vomiting.(Chloride loss) Side Effects • Metabolic alkalosis, hypernatremia, hyperkalemia and hyperosmolarity. • Electrolyte imbalance (tetany) • Seizures • Renal Calculi (Kidney stone) Dosage & Administration ADULT & PEDIATRIC Initial: 1 mEq/kg IV/IO of an 8.4% solution Subsequent: 0.5 mEq/kg IV/IO of an 8.4% solution INFANT (< 1 y/o) Dosage is the same but using a 4.2% solution Revision Date 11/01/2005 447 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference SODIUM BICARBONATE MED REF Page 448 TOC Special Considerations • Administration should be accompanied by controlled hyperventilation to blow off excess CO2. Bicarbonate administration produces carbon dioxide, which crosses cell membranes more rapidly than bicarbonate, potentially worsening intracellular acidosis. • May precipitate with Epinephrine and in calcium solutions. • May increase edematous or sodium-retaining states. • May worsen congestive heart failure Revision Date 11/01/2005 448 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference METHYLPREDNISOLONE MED REF Page 449 TOC (Methylprednisolone) Medication Methylprednisolone is a synthetic steroid that suppresses acute and chronic inflammation. In addition, it potentiates vascular smooth muscle relaxation and may alter airway hyperactivity. A new indication is for reduction of posttraumatic spinal cord edema. Mechanism of Action • Beta-adrenergic agonists activity (vascular smooth muscle relaxation) • May stabilize cell membranes by decreasing permeability. • Increases blood pressure by increased sodium and water reabsorption. (aldosterone effect) • Increases blood sugar by stimulating gluconeogenesis. • Increases protein metabolism. • May prevent the release of histamine and excess lactic acid accumulation. • Demonstrable effects are evident in one hour. Indications • Bronchial asthma and other bronchospastic states unresponsive to conventional treatment. • Life-threatening shock states to reduce the body's inflammatory response. Contraindications • Use with caution in patients with GI hemorrhage and diabetes mellitus. • Systemic fungal infection Side Effects • No acute toxic effects for short-term therapy. • Long term therapy: 1. Hypertension 2. Hyperglycemia / Hypokalemia 3. Fluid and electrolyte shifts 4. Sodium and water retention 5. Aggravation of diabetes mellitus Revision Date 11/01/2005 449 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference METHYLPREDNISOLONE MED REF Page 450 TOC Dosage & Administration ADULT: 125 mg SLOW IV over 3 minutes. PEDIATRIC: 2 mg/kg SLOW IV over 3 minutes Weight (kg) Dose (mg) 5 10 15 20 25 30 35 40 45 50 55 60 65 10 20 30 40 50 60 70 80 90 100 110 120 130 Volume (ml) 0.2 0.3 0.5 0.6 0.8 1.0 1.1 1.3 1.4 1.6 1.8 1.9 2.1 Special Considerations • Hypoglycemic responses to insulin and oral hypoglycemics may be blunted • Oral contraceptives and estrogens drugs may increase effects. • Administer with caution in diabetes mellitus. Revision Date 11/01/2005 450 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference SUCCINYLCHOLINE CHLORIDE MED REF Page 451 TOC (Anectine) Medication A depolarizing neuromuscular blocking agent used specifically to facilitate endotracheal intubation by paralysis of muscular tone. Mechanism of Action Succinylcholine produces complete neuromuscular paralysis by depolarizing the neuromuscular end plate and preventing repolarization by binding to the receptors for acetylcholine. In doing so, it produces minute, but visible muscle contractions called fasciculation’s. The paralysis following administration is selective, initially involving consecutively the levator muscles of the face, muscles of the glottis, and finally the intercostals, diaphragm and all other muscles. In general for therapeutic dosages, the onset time is ≈ 45 seconds and the effects last ≈ 5 minutes Indications To induce paralysis in order to facilitate endotracheal intubation Contraindications • Inability to control airway or support ventilations with a BVM. • Malignant Hyperthermia • Penetrating eye injury (Succinylcholine increases intraocular pressure) • Patients at risk for hyperkalemia: 1. Old burns (>7 days or more post burn) 2. Spinal cord injury (> 24 hrs) 3. Severe renal failure Side Effects • Apnea, Hypoventilation • Malignant Hyperthermia • Hypertension • Arrhythmias • Histamine mediated signs and symptoms 1. Hypotension 2. Bronchoconstriction 3. ↑ salivation, ↑ intragastric pressure 4. Rash and flushing. • ↑ intraocular pressure • Hyperkalemia and exacerbation of hyperkalemia in trauma patients Revision Date 11/01/2005 451 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference SUCCINYLCHOLINE CHLORIDE MED REF Page 452 TOC Dosage & Administration ADULT: 100 mg IV/IO PEDIATRIC: 1 mg/kg IV/IO Special Considerations • Patients with neuromuscular diseases may be resistant or very sensitive to the effects of Succinylcholine • All monitors (ECG, B/P cuff, pulse oximeter) and intubating equipment shall be in place before inducing the patient. Should the intubation be unsuccessful, the patient should be oxygenated and ventilated prior to any further attempts. Equipment to perform an emergency needle or surgical cricothyrotomy should be readily accessible. • Succinylcholine alone has no effect on perception, consciousness or pain. Administering an analgesic or sedative prior to administering this agent should blunt this. • Diazepam may reduce duration of action. • Lidocaine administration, prior to paralytic administration, reduces the rise in I.C.P. associated with paralytic endotracheal intubation. • Use with caution in patients with any of the following: 1. Personal or familial history of malignant hypertension or hyperthermia 2. Elderly or debilitated patients 3. Severe burns or trauma 4. Degenerative or dystrophic neuromuscular disease, myasthenia gravis 5. Glaucoma, eye surgery and pheochromocytoma. Revision Date 11/01/2005 452 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference TETRACAINE OPHTHALMIC SOLUTION MED REF Page 453 TOC Medication Tetracaine is a local anesthetic agent of the ester linkage type, related to procaine, used topically and by infiltration. Mechanism of Action Tetracaine prevents initiation and transmission of nerve impulses thereby effecting local anesthesia. Onset of anesthesia usually begins within 30 seconds and lasts a relatively short period. Indications For situations in which a rapid and short acting topical ophthalmic anesthetic is indicated, Tetracaine may be used. It is most often used in the field treatment of burns to the eyes. Contraindications • Known hypersensitivity • Open or Disrupted globe Side Effects Transient reactions may occur, and include: • • • Stinging Burning Conjunctival redness Dosage & Administration ADULT & PEDIATRIC: 1–2 drops prn in injured eye(s) Special Considerations • Prolonged use results in diminished duration of anesthesia. • Patients should be advised not to touch or rub the eye(s) until the effect of the anesthetic has worn off. • On very rare occasions, a severe, immediate, allergic corneal reaction may occur characterized by acute diffuse epithelial keratitis with filament formation and/or sloughing of large areas of necrotic epithelium. Revision Date 11/01/2005 453 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference THIAMINE MED REF Page 454 TOC Medication A vitamin B complex (B1), that occurs naturally and is produced synthetically. Most vitamins required by the body are obtained through dietary intake. But certain states, such as alcoholism and malnutrition, the intake, absorption, and use of Thiamine may be severely affected. The brain is extremely sensitive to Thiamine deficiency. Mechanism of Action Thiamine is essential for the normal metabolism of carbohydrates and fats. Thiamine combines with ATP to form Thiamine pyrophosphate coenzyme, a necessary component for carbohydrate metabolism. Indications • Patients presenting with S/S of alcohol toxicity, Wernicke’s syndrome or Korsakoff’s psychosis. • Unconscious patient of unknown etiology. Thiamine should be administered prior to D50 and Naloxone. Contraindications Known hypersensitivity Side Effects • Hypotension (from rapid injection or large dose) • Diaphoresis • N\V • Weakness • Tingling Dosage & Administration ADULT: 100 mg IV/IO or IM or 50 mg IV/IO and 50 mg IM PEDIATRIC: 10–25 mg IV/IO or IM Special Considerations • In alcoholics, Thiamine deficiency causes Wernicke’s syndrome, an acute and reversible encephalopathy (brain dysfunction) characterized by: 1. Ataxia (defective muscular coordination) 2. Eye muscle weakness 3. Mental derangements. • A more serious complication of Thiamine deficiency is known as Korsakoff’s psychosis, a memory disorder that may be irreversible once it becomes established. Since Thiamine is utilized in carbohydrate metabolism, these syndromes may be precipitated by the administration of dextrose to the alcoholic with pre-existing Thiamine deficiency. Revision Date 11/01/2005 454 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference VALIUM MED REF Page 455 TOC Medication A CNS depressant (sedative) derived from benzodiazepine, with muscle-relaxant and anticonvulsant properties, Diazepam is used to relieve anxiety and tension and for the treatment of seizure disorders. Mechanism of Action • Diazepam induces calming effects by depressing the limbic system (emotional intensity) and R.A.S. (level of alertness) thereby alleviating anxiety and inducing amnesia. • Suppresses the spread of seizure activity through the motor cortex of the brain and elevates seizure threshold. • Relaxes skeletal muscles and has no autonomic actions and does not inhibit conditioned reflexes. Indications • Sedation for acute stress anxiety reactions • Acute alcohol withdrawal to relieve acute delirium tremens or agitation. • Status epilepticus and severe, recurrent convulsive seizures • Sedation before cardioversion in conscious patients. • Isolated musculoskeletal injuries. Contraindications • Alcohol or sedative ingestion prior to administration • Respiratory depression • Shock, coma, or acute alcoholic intoxication with ↓ V/S • Caution in pregnancy, especially the 1st trimester Side Effects • Drowsiness, confusion, stupor, fatigue • Ataxia (shaky movements and unsteady gait) • Transient Hypotension • Respiratory depression Dosage & Administration ADULTS: 2 – 10 mg Slow IV/IO (4 – 20 mg PR) Until desired dose or effect • Lower doses (2 – 5 mg) for elderly / debilitated patients. PEDIATRICS: 0.2 – 0.3 mg/kg Slow IV/IO (0.4 – 0.6 mg/kg PR) Until desired dose or effect • Maximum dose 5 mg if patient < 2yrs. • Maximum dose 10 mg if patient > 10yrs. Revision Date 11/01/2005 455 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference Revision Date 11/01/2005 VALIUM MED REF Page 456 TOC 456 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference VALIUM MED REF Page 457 TOC Special Considerations • In order to reduce the possibility of venous thrombosis, phlebitis, local irritation, swelling, and rarely, vascular impairment, Diazepam should be injected slowly and small veins, such as those on the dorsum of the hand or wrist, should not be used. Extreme care should be taken to avoid intra-arterial administration or extravasation. • Diazepam should not be mixed or diluted with other solutions or medications. • Has a cumulative and potentiating effect with alcohol and other sedative drugs. • Respiratory depression is generally caused by rapid IV administration. Revision Date 11/01/2005 457 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference VASOPRESSIN MED REF Page 458 TOC (Pitressin) Medication Vasopressin is an antidiuretic hormone naturally produced by your body. Its primary function in the body is to regulate extracellular fluid volume by affecting renal handling of water. Mechanism of Action  Potent vasoconstrictor  Increased blood pressure and systemic vascular resistance  Increases cerebral blood flow to a greater degree than epinephrine  Improves cerebral oxygenation  Decreases:  Cardiac output  Heart rate  Left ventricular oxygen consumption  Myocardial contractility Indications  Ventricular fibrillation/Pulseless Ventricular Tachycardia  PEA  Asystole Contraindications  Bronchospasm  Epilepsy  Heart disease  Kidney disease  Heart or blood vessel disease Side Effects  Abdominal or stomach cramping  Dizziness  Nausea and/or vomiting  Chest pain  Coma  Confusion  Seizures  Swelling to face, hands, feet or mouth Dosage and Administration  Adults: 40 U IV/IO repeat q 5 minutes  Pediatrics: Not recommended Special Considerations  None in cardiac arrest Revision Date 03/01/2010 458 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference VECURONIUM MED REF Page 459 TOC (Norcuron) Medication A non-depolarizing neuromuscular blocking agent Mechanism of Action Through competitive inhibition, Vecuronium blocks cholinergic receptors at the motor end plate initiating a neuromuscular paralysis within ≈ 3 minutes that lasts ≈ 25–30 minutes. Indications • To sustain neuromuscular paralysis after a patient has been completely paralyzed to facilitate intubation. • Provide muscle relaxation during mechanical ventilation. Contraindications • Hypersensitivity • Patient who is not intubated • Myasthenia gravis Side Effects • Bradycardia • Apnea, Hypoventilation Dosage & Administration ADULT: 10 mg IV/IO PEDIATRIC: No protocol Special Considerations None Revision Date 11/01/2005 459 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference VERSED MED REF Page 460 TOC (Midazolam) Medication Midazolam is a short acting benzodiazepine with CNS depressant, hypnotic, anticonvulsant and sedative properties. Midazolam is 3 – 4 times as potent as Diazepam on a milligram to milligram basis. Mechanism of Action Used for its rapid onset, Midazolam acts on GABA receptors producing anesthetic, sedation and amnesic effects. Respiratory and cardiovascular depression are also associated with the administration of Midazolam. Indications • Status epilepticus and severe, recurrent convulsive seizures • Sedation for acute stress anxiety reactions • Sedation before cardioversion and/or Intubation in conscious patients • Used in conjunction with other medications during emergent intubation situations. • Sedation of previously intubated patient Contraindications • Hypersensitivity • Pre-existing respiratory depression due to drugs or C.N.S. dysfunction. Side Effects • Respiratory depression • Amnesia • Mild hypotension • CNS depression / Drowsiness • Laryngospasm / Bronchospasm • • • • Euphoria Confusion Tremor Slurred Speech Dosage and Administration ADULT: 2 – 5 mg IV/IO/IN (IM if IV/IO unavailable: 4 – 10 mg) PEDIATRIC: 0.1 – 0.2 mg/kg IV/IO/IM/IN Special Considerations • Potentiates respiratory depression and sedative effects of other CNS depressants. • Narcotics accentuates hypnotic effect • Generally need 5 mg maximum for conscious sedation • ReMidazolam with flumazenil Revision Date 08/01/2007 460 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference XOPENEX MED REF Page 461 TOC (Levalbuterol HCL) Medication Xopenex (Levalbuterol HCl) is a purified form of racemic albuterol and is a short-acting beta2 -adrenergic agonists. Xopenex is used for the treatment and prevention of bronchospasms. Mechanism of Action • Xopenex has been shown to promote bronchial smooth muscle relaxation and to decrease release of pulmonary histamines within the bronchial tree with the net effect being broncodilation • Onset of action is within 5 minutes and may provide relief of symptoms for 4 to 8 hours. • Xopenex can produce the same desired effects as Albuterol with less than half the dose, a longer duration of action, and fewer sympathetic side effects seen with other beta2 -adrenergic agonists. Indications For the treatment and prevention of bronchospasms associated with reversible reactive airway disease: • Bronchospasm • COPD (bronchitis, emphysema) • As well as other conditions that may cause acute narrowing of the airway. (i.e. Allergic reactions) Contraindications Hypersensitivity to Albuterol, Xopenex, or any of its components Side Effects • • • • • Tremors Anxiety Nausea / Vomiting Tachycardia Headache • • Cough with increase in sputum Hypertension LESS COMMON: • Arrhythmias • Palpitations Dosage and Administration ADULT: 1.25 mg in 3 ml of NS solution via hand held/face mask nebulizer PEDIATRIC: 0.63 mg in 3 ml of NS solution via hand held/face mask nebulizer.  For children < 4 years of age Special Considerations • Caution should be used in patients with cardiovascular disorders, hypertension, convulsive disorders, hyperthyroidism, and diabetes Revision Date 11/01/2005 461 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference ZOFRAN MED REF Page 462 TOC Ondansetron (Ondansetron) Medication Ondansetron blocks the actions of chemicals in the body that can trigger nausea and vomiting Mechanism of Action  Blocks the effects of serotonin at 5-HT3–receptor sites (selective antagonist) located in vagal nerve terminals and the chemoreceptor trigger zone in the CNS. Indications  Prevention of nausea and vomiting, especially associated with chemotherapy or radiation therapy Contraindications and Precautions Contraindicated in:  Hypersensitivity  Orally disintegrating tablets contain aspartame and should not be used in patients with phenylketonuria. Use Cautiously in:  Liver impairment (daily dose not to exceed 8 mg)  Abdominal surgery (may mask ileus)  Pregnancy, lactation, or children ≤3 yr (safety not established). Side Effects  Headache, dizziness, drowsiness and fatigue  Constipation, diarrhea, abdominal pain  Dry mouth Dosage and Administration ADULT: 8mg oral dissintegrating tablet (ODT) PO May be repeated every 15 mins to max of 16mg OR 4-8mg IV/IO/IM/IN May be repeated in 15 mins to max of 16mg PEDIATRIC: (8kg-30kg) 4mg ODT PO (>30kg) 8mg ODT PO May be repeated every 15 mins to max of 16mg OR Revision Date 11/01/2012 462 Montgomery County Hospital District-EMS Clinical Guidelines – Medicine Reference ZOFRAN MED REF Page 463 TOC OR (8kg-30kg) 1-2mg (>30kg) 2-4mg (>45kg) Use Adult Dosing May be repeated every 15 mins to max of 16mg Do not attempt to push the Ondansetron (Ondansetron) ODT Tablets through the foil backing. With dry hands, PEEL BACK the foil backing of 1 blister and GENTLY remove the tablet. IMMEDIATELY place the tablet on top of the tongue where it will dissolve in seconds, then swallow with saliva. Administration with liquid is not necessary. Revision Date 11/01/2012 463 This Page Intentionally Left Blank SPECIAL RESPONSE SCENARIOS Montgomery County Hospital District-EMS Clinical Guidelines – Special Response Scenarios Rehabilitation of Responders at Emergencies SRS 01 Page 466 TOC Criteria and History : • Historical Findings: - Complaint-free responder with incident-related exertion/environmental exposure Rehab Entry Assessment : • Rapid Assessment: - For each responder entering rehab:  Rapid visual impression- further assess those who look sick/distressed  Ask simply “Are you feeling OK?” Go to correct SDO for any complaint voiced During 10 minute minimum rest/ vital sign recovery period before continuing: • • • Have responders remove PPE, including turnout pants Assure personnel checked-in to rehab by any responder accountability system in use Initiate oral rehydration and encourage active/passive cooling measures Rehab Area Assessment (after minimum 10 minute initial rest/ recovery period) : • • Ask each responder in rehab how they are doing. Explore answers of concern. Assess vital signs, including at least below parameters, and assign each responder to “Green”, “Yellow”, or “Red” level of the Post-recovery Responder Assessment Tool Post-Recovery Responder Assessment Tool Parameter Temperature (oral, tympanic, temporal) Blood pressure Pulse oximetry Heart Rate Revision Date 11/01/2012 Acceptable Work Limits <100.6 ° F Not hypertensive relative to personal baseline Greater than 94% SpO2 Less than 101 beats per minute 466 Montgomery County Hospital District-EMS Clinical Guidelines – Special Response Scenarios Rehabilitation of Responders at Emergencies SRS 01 Page 467 TOC Primary Interventions (Based on Post-Recovery Responder Assessment Outcome) : Green: • Release from Rehab Sector as per on-scene accountability procedure Yellow: • • • Address any specific complaints with appropriate SDO(s). When complaint free, then: Ten (10) additional minutes cooling/rest/oral rehydration for persons with pulse >100 after initial ten (10) minutes in rehab. Attempt to disengage responder from incident stimuli to facilitate return to normal resting heart rate. Assure this responder remains accompanied by a medically-trained responder. Red : • • • • • • Immediate O2 Exposure, for cooling and assessment Complaint-specific care initiated by nearest trained provider Chilled NS infusion for responder with altered mental status with Temp >103.9 °F. Continue cold fluids to a maximum of 2 Liters OR until return of mentation and/or temperature <100.6 °F. TRANSPORT THESE PERSONS If after 20 minutes of climate management and oral rehydration responder remains tachycardic (>100), is in sinus tachycardia, and has no other complaint, administer up to 2 liters of normal saline IV.  If, after IV fluids, pulse does not return to <100, EMS will transport to an appropriate hospital. Tachycardia other than sinus tachycardia will be managed under the applicable SDO, and will not be cleared for return to incident duties under this algorithm.  If pulse after IV fluids is less than or equal to 100, responder temperature is less than 100.6°F, and responder has at no time expressed any other medical complaint, and remainder of assessment is patient does not require EMS transport if: 1. Incident commander or ranking official of patient’s department agrees not to return the responder to response activities during this shift. 2. Responder can be directly observed by departmental personnel for at least four (4) hours. Revision Date 11/01/2012 467 APPENDIX Montgomery County Hospital District-EMS Clinical Guidelines – Appendix 12 LEAD GUIDE APP 01 Page 469 TOC 12-Lead ECG in Relation to Anatomy of the Heart Revision Date 11/01/2012 469 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Revision Date 11/01/2012 12 LEAD GUIDE APP 01 Page 470 TOC 470 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix AMBULANCE ACCEPTABLE ABBREVIATIONS APP 02 Page 471 TOC Below is a list of acceptable abbreviations that may be used for filing Medicare claims. Please contact our office if additional abbreviations become common in the industry so that we may update the list. Abd Abdomen, abdominal DM Diabetes mellitus ABG Arterial blood gases DOA Dead on arrival ADM Admission EKG Electrocardiogram A-fib Atrial fibrillation EOA Esophageal obturator airway ALS Advanced life support ER Emergency room ASA Aspirin ETOH Ethanol alcohol ASHD Arteriosclerotic heart disease FUO Fever of unknown origin BBB Bundle branch block fx Fracture bilat. Bilateral GEN General BLS Basic life support HM Home BP, B/P Blood pressure Hx History c/c Chief complaint IM Intramuscular CHF Congestive heart failure inj, injs Injuries CNS Central nervous system IV Intravenous COPD Chronic obstructive pulmonary disease LOC Loss of consciousness MAST Miltary anti-shock trousers CPR Cardiopulmonary resuscitation MVA Motor vehicle accident C-spine Cervical spine NH Nursing home NTG Nitroglycerin O2 Oxygen OBS Organic brain syndrome CTR Center CVA Cerebrovascular accident disch Discharged (from hospital) Revision Date 11/01/2012 471 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix PVS, PVCs Premature ventricular contractions RBBB Right bundle branch blook RSCH Research resp. Respiration SNF Skilled nursing facihty SOB Shortness of breath ST Street THPY Therapy TIA Transient ischemic attack TKO To keep open Tx Treatment Vfib,V-fib Ventricular fibrillation VS, V/S Vital signs Vtach/Vtach Ventricular tachycardia Revision Date 11/01/2012 AMBULANCE ACCEPTABLE ABBREVIATIONS APP 02 Page 472 TOC 472 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix APGAR SCORE APP 03 Page 473 TOC SIGN Heart Rate 0 Absent 1 Below 100 Respiration (effort) Absent Slow and irregular Muscle Tone Limp Some flexionextremities Active; good motion in extremities Irritability No Response Crying; some motion Crying; vigorous Skin Color Revision Date 11/01/2012 Bluish or paleness Pink or typical newborn color; hands and feet are blue 2 Over 100 Normal crying Pink or typical newborn color; entire body 473 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Revision Date 11/01/2012 CAPNOGRAPHY APP 04 Page 474 TOC 474 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Revision Date 11/01/2012 CAPNOGRAPHY APP 04 Page 475 TOC 475 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Revision Date 11/01/2012 CAPNOGRAPHY APP 04 Page 476 TOC 476 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Revision Date 11/01/2012 CAPNOGRAPHY APP 04 Page 477 TOC 477 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Revision Date 11/01/2012 CAPNOGRAPHY APP 04 Page 478 TOC 478 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix GLASCOW COMA SCALE ADULT AND PEDIATRIC COMBINED APP 05 Page 479 TOC GLASGOW COMA SCALE (GCS): Adult & Pediatric Combined GCS Note: Modifications for age appropriate response for infant/young child are typed in bold print. EYE OPENING RESPONSE 4 pts = Open spontaneously 3 pts = To verbal stimuli To speech, to shout 2 pts = To painful stimuli 1 pt = No response BEST VERBAL RESPONSE 5 pts = Oriented & converses Appropriate words and phrases Cries appropriately, coos, babbles 4 pts = Disoriented & converses Irritable cry 3 pts = Inappropriate words Inappropriate crying/screaming 2 pts = Incomprehensible sounds/words Grunts BEST MOTOR RESPONSE 6 pts = Obeys commands Normal spontaneous movement 5 pts = Localizes pain Withdraws to touch 4 pts = Flexion withdrawal Withdraws to pain 3 pts = Flexion abnormal (decorticate) 2 pts = Extension 1 pt = No response (decerebrate) 1 pt = No response Risk of injury is high with GCS < 14 COMA is defined by GCS = 8 Any patient with a GCS < 9, consider intubation and hyperventilate at 20 to 24 breaths per minute to reduce cerebral swelling. Revision Date 11/01/2012 479 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix INFUSION CALCULATIONS APP 06 Page 480 TOC Drip Rates For IV Tubing Ml/hr 30 This is TKO 45 60 75 100 125 150 175 200 225 250 300 Macro Drip IV Tubing10gtts/ml gtts/min 5 8 10 13 17 21 25 29 33 38 42 50 Mini Drip IV Tubing 60gtts/ml gtts/min 30 45 60 75 100 - DOPAMINE Drip Rate 400 mg of Dopamine in 250 cc Solution 5 Mcg 10 Mcg 15 Mcg 20 Mcg Weight/Kg gtts/min gtts/min gtts/min gtts/min 40 8 16 24 36 50 10 20 30 40 60 12 24 36 48 70 14 28 42 56 80 16 32 48 64 90 18 36 54 72 100 20 40 60 80 110 22 44 66 88 120 24 48 72 96 130 26 52 78 104 140 28 56 84 112 150 30 60 90 120 160 32 64 96 128 170 34 68 102 136 180 36 72 108 144 190 38 76 114 152 200 40 80 120 160 Revision Date 11/01/2012 480 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix INFUSION CALCULATIONS APP 06 Page 481 TOC LIDOCAINE Drip Rate For pre-mixed bag of 2 g/500 ml (4mg/ml) Lidocaine Drip Rate (per mg/min dose) mg/min ml/hr 1 15 2 3 30 45 4 60 Pediatric Lidocaine Infusion Dose: 20 – 50µg/kg/min Revision Date 11/01/2012 Preparation: 100 mg lidocaine in 100 ml NS Dosage: 20 µg/kg/min 30 µg/kg/min 40 µg/kg/min 50 µg/kg/min 6 drops/min per 5 kg 9 drops/min per 5 kg 12 drops/min per 5 kg 15 drops/min per 5 kg 481 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Revision Date 11/01/2012 MALLAMPATI SIGNS APP 07 Page 482 TOC 482 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix MCHD STROKE SCALE APP 08 Page 483 TOC MCHD-EMS Stroke Assessment Scale FACIAL DROOP • BOTH SIDES OF THE FACE MOVE EQUALLY • ONE SIDE OF FACE DOES NOT MOVE AT ALL ARM DRIFT • BOTH ARMS MOVE EQUALLY OR NOT AT ALL • ONE ARM DRIFTS COMPARED TO THE OTHER SPEECH • PATIENT USES CORRECT WORDS WITH NO SLURRING • SLURRED OR INAPPROPRIATE WORDS OR MUTE ATAXIA • FINGER TO NOSE • HEEL TO SHIN Revision Date 11/01/2012 483 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix OXYGEN DURATION APP 09 Page 484 TOC Formula for Calculating Oxygen Duration Gage Pressure-200psi x Cylinder constant Flow rate in LPM =Duration in Min Cylinder Endurance Cylinder Size D E G M H/k Cylinder Constants 0.16 0.28 2.41 1.56 3.15 Capacity (liters) Flow Rate (liters/min 2 4 6 8 10 15 300 600 1000 3450 6500 2:30 1:15 0:50 0:35 0:30 0:20 5:00 2:30 1:40 1:10 1:00 0:40 8:20 4:10 2:45 2:05 1:40 1:05 28:45 14:20 9:35 7:10 5:45 3:50 54:00 27:00 18:00 13:30 11:00 7:15 Endurance times in hours and minutes are approximations based on full tank pressures O2 Flow Rates and % O2 Device NC Simple Face Mask NRB mask BVM Revision Date 11/01/2012 Flow Rate 3-6 LPM 6-12 LPM 10-12 LPM 10_15 LPM O2 % 25-40% 40-60% 90-100% 100% c Reservoir 484 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix PAIN ASSESSMENT APP 10 Page 485 TOC Assessing Pain Onset/Origin What were you doing when the pain began? Did your stomach begin to hurt immediately after you were kicked by the horse (somatic) or several hours later after you vomited (visceral)? Somatic pain usually comes on abruptly while visceral pain more gradually. Provokes What makes the pain worse or better? Does your chest hurt each time you take a breath and move your intercostals muscles (somatic) or is it made worse with exertion and anxiety (visceral)? Quality What does the pain feel like? Is it sharp like a stabbing pain (somatic) or dull like a throbbing ache or pressure (visceral)? Referred/Region Where does it hurt? Is you pain only in your shoulder you injured, (somatic) or does the pain radiate from your abdomen into your back (visceral)? Severity Can you rate your pain on a scale of 1 to 10? Time How long have you had this pain? Has it been there only since the injury (somatic) or for many months (neuropathic)? The Wong-Baker Faces Pain Rating Scale Designed for children aged 3 years and older, the Wong-Baker Faces Pain Rating Scale is also helpful for elderly patients who may be cognitively impaired. If offers a visual description for those who don't have the verbal skills to explain how their symptoms make them feel. To use this scale, you should explain that each face shows how a person in pain is feeling. That is, a person may feel happy because he or she has no pain (hurt), or a person may feel sad because he or she has some or a lot of pain. Face 0 is very happy because he or she doesn't hurt at all. Revision Date 11/01/2012 485 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix PAIN ASSESSMENT APP 10 Page 486 TOC Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad. You should point to each face using the words to describe the pain intensity. The patient should then choose the face that best describes how they feel. Revision Date 11/01/2012 486 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix RULE OF NINES APP 11 Page 487 TOC Infant Revision Date 11/01/2012 487 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix SUBJECT IN CUSTODY RISK ASSESSMENT SCALE APP 12 Page 488 TOC SUBECT IN CUSTODY RISK ASSESSMENT SCALE (SICRAS) The Subject in Custody Risk Assessment Scale was developed to provide Law Enforcement, Corrections, and EMS Personnel with a means to rapidly assess an in-custody subject’s risk of sudden death based on known symptoms and risk factors. Directions: Begin at the first observed sign or symptom. Add the numbers for each sign or symptom which applies. Alcohol Intoxication Acute Alcohol Intoxication (BAC 0.25 or above) History of Alcoholism Cocaine Intoxication Methamphetamine Intoxication Drug Intoxication (other) Bizarre Behavior Aggressive Behavior Shouting Paranoia Violence Against Others Above Normal Physical Strength Sudden Tranquility / Lethargy Moderate Physical Activity Intense Physical Activity Obesity “Big Bellies” Hyperthermia Hypotonicity of Skeletal Muscles Antipsychotic Drug Use History of Schizophrenia Male Ineffectiveness of OC Spray Cyanosis of Lips/Nail Beds Confusion – Disorientation 1 3 2 4 3 2 2 2 2 3 2 3 2 3 3 1 2 4 4 2 2 1 2 5 3 A score 16 or above indicates the subject is at extreme risk for sudden in-custody death syndrome. Immediate medical attention is necessary. Revision Date 11/01/2012 488 Montgomery County Hospital District-EMS SUBJECT IN CUSTODY RISK ASSESSMENT SCALE Clinical Guidelines – Appendix APP 12 Page 489 TOC Score 10 – 16 Subject is at HIGH risk for Subject in Custody Death Syndrome (SICDS). Immediate evaluation by EMS personnel is necessary. Medical treatment may be warranted. Subject should be closely monitored Score 5 – 10 Subject is at MODERATE risk for SICDS. Subject should be reevaluated by another officer/provider familiar with the SICRAS system and SICDS. Subject should be monitored by police, corrections, and/or EMS personnel. Score 0 – 5 Subject is at LOW risk for SICDS based on known risk factors. Personnel should be watchful for any signs of distress which would preclude the SICRAS score. The following conditions or circumstances represent serious, or immediate, threats to safety which necessitate immediate medical treatment or evaluation and supersede the Subject in Custody Risk Assessment Scale. Loss of consciousness Seizure Anaphylactic shock Respiratory rate < 6 per minute Resting heart rate < 40 or > 140 Severe headache Medical Shock (any cause) Chest pain Gagging, gasping, or choking > 4 minutes after OC ingestion Obvious respiratory distress The SICRAS and other guidelines presented here cover only conditions and circumstances known to date. It is impossible for us to cover all circumstances with which personnel may be faced. An officer should rely on his common sense, experience, and training. A good rule of thumb is that when conducting an ABCs survey of a subject, any obvious impairment of the Airway, Breathing, or Circulation requires evaluation by medical personnel. When in doubt, have it checked out. Revision Date 11/01/2012 489 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix TRAUMA SCORES APP 13 Page 490 TOC PEDIATRIC TRAUMA SCORE (PTS): CATEGORY DEFINITIONS COMPONENT Size Airway +2 Child/adolescent, >20 kg Normal Consciousness Awake Palpable pulseSystolic blood pressure Fracture Cutaneous Palpable radial or brachial pulse Good peripheral pulses, perfusion >90 mm Hg None seen or none suspected No visible injury +1 -1 Toddler, 11-20 kg Infant, < 10 kg Assisted 02, mask, cannula Obtunded; lost consciousness Palpable femoral pulse Peripheral pulses, pulses palpable 5190 mm Hg Single closed Fx anywhere orfracture suspected Contusion, abrasion; laceration < 7 cm; not through fascia Intubated; ETT, EOA, Cric Coma; unresponsive Weak or no pulses < 50 mm Hg SCORE Open, multiple Fx Tissue loss; and GSW/Stab; through fascia Total Score (PTS) Totals can range from a +12 to a -6 with the range of <8-9 being the critical break point for transport to a comprehensive pediatric trauma care facility. Revision Date 11/01/2012 490 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Adult Revised Trauma Score GCS: Respiratory Rate: Respiratory Expansion: Systolic Blood Pressure: Capillary Refill: Total Trauma Score: Trauma Score Percentage Survival Revision Date 11/01/2012 14 - 15 11 - 13 8 - 10 5-7 3-4 10 - 24 / Min. 25 - 35 / Min. 36 Min. or greater 1 - 9 / Min. None Normal Retractive / None 90 mm Hg or greater 70 - 89 mm Hg 50 - 69 mm Hg 0 - 49 mm Hg No Pulse Normal Delayed None TRAUMA SCORES APP 13 Page 491 TOC 5 4 3 2 1 4 3 2 1 0 1 0 4 3 2 1 0 2 1 0 1 - 16 16 15 14 13 12 11 10 9 8 7 99 98 96 93 87 76 60 42 26 15 6 8 5 4 4 2 3 1 2 0 1 0 491 Montgomery County Hospital District-EMS EZ IO HUMERAL PLACEMENT PROVISIONAL PROCEDURE Clinical Guidelines – Appendix APP 14 Page 492 TOC EZ IO HUMERAL PLACEMENT Indication: Any adult patient (>45 kg) for who, you are unable to obtain peripheral vascular access after 2 attempts or 90 seconds and that has one or more of the following:  Hemodynamic instability  Respiratory compromise  Patients requiring EMERGENCY medicinal therapy or volume replacement May be used without consult in Cardiac Arrest and Post Resuscitation Management Consult Required for Placement in all other patients  Any patient that treatment warrants vascular access, but peripheral access has been unobtainable  UNDER NO CIRCUMSTANCES should it be used for prophylactic care Contraindications: 1. Patient’s weighing less than 45 kg. 2. Any patient that may receive fibrinolytic or thrombolytic therapy; specific to Active MI and/or Stroke. 3. Hypoglycemic patients needing D50; EXCEPTION ONLY is Cardiac Arrest. 4. Suspected fracture of the associated humorus. 5. Prosthetic devices on the insertion site 6. Extremity that is compromised by a pre-existing medical condition. i.e. tumor or PVD 7. Overlying skin infection/trauma at placement site 8. Inability to locate the 3 anatomical landmarks for insertion 9. Excessive tissue over the insertion site. 10. Patient’s at risk of NO Transport: i.e., Unconscious Hypoglycemic (Diabetic) Equipment:  EZ-IO™ Driver  EZ-IO™ Needle Set  Chlorohexidine  IV setup and/or optional extension tubing  10cc or 20 cc Syringe  Roller gauze Revision Date 03/28/2011 492 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix EZ IO HUMERAL PLACEMENT PROVISIONAL PROCEDURE APP 14 Page 493 TOC Procedure: 1. Don PPE 2. Determine if EZ-IO™ is indicated and no contraindications are present. 3. Locate proper site for EZ-IO™ insertion. 4. HUMORAL HEAD PLACEMENT a. Expose shoulder and adduct humerus (arm against supine patient’s body) b. PRIMARY TECHNIQUE TO LOCATE INSERTION SITE Palpate and identify the mid-shaft humerus and continue palpating toward the proximal aspect of the humeral head. Identify the greater tubercle insertion site. Pinch the anterior and inferior aspects of the humeral head while confirming identification of the greater tubercle. This ensures that the midline of the humerus is identified. Consider alternative means of placement identification to ensure proper location c. ALTERNATIVE INSERTION SITE IDENTIFICATION i. Identify the acromion and the coracoid process by walking your index and middle finger along the clavicle to the shoulder’s lateral end. ii. Identify the greater tubercle insertion site approximately two finger widths inferior to the coracoid process d. Once the insertion site has been identified, place the patient’s forearm on the patient’s abdomen, leaving the elbow on the ground or stretcher. e. DO NOT ATTEMPT INSERTION MEDIAL TO THE GREATER TUBERCLE AT ANY TIME. 5. Cleanse the insertion site with Chlorohexidine using accepted aseptic technique. Remember to work from the inside to the outside in concentric circles. 6. If patient is conscious, inform patient of the EMERGENT need to perform procedure and that they might feel some discomfort until Lidocaine is administered. Obtain consent from patient; recall that the patient has the right to refuse. You may consider an anesthetic/analgesic if indicated by medical direction. 7. Prepare the EZ-IO™ Driver and Needle Set. a. Open the case and remove the driver and needle set cartridge. DO NOT USE IF SAFETY SEAL IS NOT INTACT b. Open the cartridge and attach the needle set to the driver c. Remove needle set from the cartridge. d. Inspect the Needle Set for protective cap, 5 and 10 mm indices, and if the needle set is intact e. Remove the protective cap from the needle set. 8. Begin insertion of the EZ-IO™ a. Hold the EZ-IO™ Driver in one hand and stabilize the leg near the insertion site with the opposite hand. b. Position the driver at the insertion site at a 90o angle to the bone surface. c. Power the driver through the skin at the insertion site until it makes contact with bone. Revision Date 03/28/2011 493 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix EZ IO HUMERAL PLACEMENT PROVISIONAL PROCEDURE APP 14 Page 494 TOC d. Evaluate the EZ-IO™ needle for the 5 mm mark 9. Power the EZ-IO™ Driver and continue insertion until the flange (base) of the EZIO™ needle set touches the skin OR a sudden lack of resistance is felt, indicating entry into the marrow cavity. 10. Remove the driver from the needle set. 11. Remove the stylet from the catheter. DO NOT REPLACE or ATTEMPT to recap the needle set. 12. Confirm proper EZ-IO™ Catheter tip position by checking for several of the following: a. IO catheter standing at 90o and firmly seated. b. Blood at tip of the stylet. c. Aspiration of marrow d. Bolus and flow fluid through the needle with no evidence of extravasation. 13. Connect IV tubing or extension set and begin infusion. 14. Rapid Bolus site with 10 ml of NS to flush medullary space. 15. If site does not flow, consider a rebolus, pressure infusion and/or rotate needle 180o. Repeat this step as necessary. 16. Attach VidaCare wrist band 17. DISPOSE OF SHARPS Rescue of IO failure: Patients failing IO access should be rescued by A) Tibial IO placement B) Repeated attempts at standard vascular access including peripheral lines if permitted by operational protocols. C) Patients failing standard vascular access under rescue attempt “A” may undergo a second IO placement attempt in the opposite humoral head or tibia. IF PATIENT IS CONSCIOUS FOR PROCEDURE OR HAS PAIN RESPONSE 1. Administer bolus 50 mg (2.5 ml) of Lidocaine 2% SLOW push for local analgesia. This shouldprobably provide pain relief for up to 1 hour. 2. CONSULT ONLY: Consider pain management for additional discomfort/pain associated with infusion Revision Date 03/28/2011 494 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix POINT OF CARE CARDIAC MARKER PROVISIONAL PROCEDURE APP 15 Page 495 TOC Indications:  Patient(s) meeting criteria or suspicion for Acute Coronary Syndrome who are transported to Conroe Regional Medical Center or Kingwood Medical Center Contraindications:  None Equipment:     Point of Care Marker Reagent Pipette Purple top Blood Tube Equipment necessary for routine blood draw Procedure:  Don appropriate Personal Protection Equipment  Draw blood into blood tubes after obtaining vascular access  Open the Cardiac Marker Reagent and place in a horizontal position  Remove the cap from the Purple top tube  Insert pipette into purple top and fill the pipette with blood sample  Place cap back on purple top tube  Squeeze cotents of pipette onto Reagent collection site (Inoculate the Reagent)  Label blood tubes with the following information:  Date of service  Time blood was drawn  Patient’s name  Your initials  Label the Reagent with the following information:  Patient’s name  Time the Reagent was inoculated  Dispose of contaminated material in appropriate manner  Complete accompanying documentation form  Deliver Reagent, blood tubes, and documentation to receiving facility personnel so they may perform the test and obtain reading Revision Date 03/29/2006 495 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix IMPEDENCE THRESHOLD DEVICE (ResQPOD®) APP 16 Page 496 TOC Impedance Threshold Device (ResQPOD®) General: An Impedance Threshold Device (ResQPOD®) selectively impedes inspiratory gases from entering the lungs during the decompression phase (upstroke) of CPR. This generates a greater negative pressure in the thorax, allowing for an enhanced venous return to the heart. As a result of greater venous return, increased preload is accomplished, which generates a greater stroke volume during the subsequent compression phase (downstroke) of CPR, which leads to increased blood flow. Indication: Any patient (>10 kg) in cardiac arrest Contraindications:  Traumatic Cardiac Arrest  Patients <10 kg  Flail Chest  Uncontrolled hemorrhage  Patients with a pulse Procedure: 1. Begin CPR ensuring proper rate and depth, and allowing for complete chest recoil during the decompression phase of chest compressions 2. Select the airway adjunct (mask, endotracheal tube, Combitube, etc.) 3. Attach Impedance Threshold Device (ResQPOD®) to the airway adjunct used above. 4. Attach the EtCO2 detector between the ITD and the ventilation source (BVM or ventilator) 5. If ventilating with a mask (pt is not intubated):    Do not use the timing assist light CPR continues at 30 compressions : 2 ventilations Pause compressions to deliver the ventiliations 6. If patient is intubated endotracheally or with a Combitube:   Deliver a single one-second ventilation with each flash of the timing assist light Do not pause compressions to deliver ventilations. Ventilations may be asynchronous to compressions. 7. Use of this device must be discontinued once ROSC has been achieved, or when CPR is no longer necessary. Revision Date 11/25/2008 496 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Intranasal Medication Administration APP 17 Page 497 TOC Indications:  Medication administration when IV access is not obtainable or undesirable. To provide an alternative method for needleless medications delivery. Contraindications:         Facial trauma Epistaxsis Nasal congestion or discharge Recent nasal surgery Recent cocaine use Increased mucous production NG or NT tube in place Any other recognized nasal mucosal abnormality Procedure:  Patient should be in a recumbent or supine position. If the patient is sitting, compress the nares with a gloved finger for 1-2 minutes after administration  Draw up medication into a 1 ml or 3 ml syringe with luer-lock tip  Expel any air within the syringe  Attach the MAD to the syringe and confirm that it is secured firmly to the syringe  Visually inspect nares and chose the largest nare or the one with the least obstruction  Insert syringe with the MAD attached into the nares until resistance is met (approximately 1.5 cm)  Timing the respirations, depress plunger rapidly upon patient exhalation but before inhalation  Briskly compress the syringe plunger rapidly upon patient exhalation but before inhalation.  The MAD is reusable on the same patient, dispose after each patient Precaution and Comments:    No more than 1 ml of medication should be administered per nostril No more than 0.5 ml of medication should be administered per nostril for children under 10 years May repeat administration q 5 minutes Revision Date 08/01/2007 497 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Induced Hypothermia APP 18 Page 498 TOC Indications:      Any nontraumatic and nonhemorrhagic arrest or post arrest patient over the age of 16 years who is NOT in an awake and alert status with purposeful neurologic function. Post arrest patient with GCS <9 Initial temperature > 34°C (93.2ºF) Patent airway secured with endotracheal tube (preferred) or combitube. OR Any adult nontraumatic and nonhemorrhagic cardiac arrest greater than 5 minutes without previous signs of hypothermia Contraindications:  Traumatic arrest  Cardiac arrest resulting from or associated with hemorrhage  Pregnant female with obviously gravid uterus  Patient whose airway is not managed with either an endotracheal tube or Combitube unless patient does not respond to CPR for greater than five minutes General Standards:  Patients will be cooled to a target range of 33°-34°C (91.4°F - 93.2°F)  Patients develop metabolic alkalosis with cooling. Do not hyperventilate.  Patent airway secured with endotracheal tube (preferred) or combitube.  Otherwise, do not induce hypothermia unless patient does not respond to CPR for greater than five minutes. Equipment needed:  1-liter bags of NaCl IV solution at a temperature of 4°C (39°F)  IV Tubing  Pressure infusion device  Ice packs (optional)  Midazolam (no consult needed)  Vecuronium Procedure:  Obtain Temperature prior to inducing hypothermia  Perform and document Neurological Assessment  Perform 12-Lead  If Temperature >34°C (93.2°F) and above criteria are met,  Establish IV/IO infusion using cooled saline  Infuse 40 ml/kg of cooled saline via pressure infuser while enroute to an approved facility. Do not delay transport for the purpose of cooling.  Monitor patient and continue treatment with appropriate SDO  Control shivering with:  Midazolam 0.1 mg/kg IV/IO  If Midazolam does not control shivering • Vecuronium 0.1mg/kg IV/IO (max 10 mg) Revision Date 03/01/2010 498 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix IMPLANTABLE VENOUS ACCESS DEVICE (iVAD) APP 19 Page 499 TOC General:  This procedure is to be considered a sterile procedure and should always be performed with the patient or care-giver’s consent. The iVAD (also refereed to as a Port-A-Cath) should be accessed prior to departing the scene. At NO TIME should the device be accessed while the ambulance is in motion, so as to minimize damage to the site.  This skill is Paramedic Level Skill only.  The iVAD is a surgically inserted device connected to the subclavian vein and it is beneath the skin. Access should ALWAYS occur with a Huber needle. The device is ALWAYS heparinized when not in use.  The iVAD should only be accessed with a Huber needle. Other needles will damage and ruin the device.  Care should be taken to ensure that this procedure is performed in a near sterile environment. The most aseptic technique precautions should be used.  An attempt to withdraw should be made and a minimum of 10cc of blood must be evacuated to remove heparin from the device. If you are unable to obtain a blood return from the site, attempt to flush and observe for extravasation of fluid. If the site will not flush DISCONTINUE the access. Policy:  Accessing the iVAD may be performed in lieu of peripheral vascular access when the patient has a medical condition requiring medication or fluid resuscitation therapy.  This skill is Paramedic Level Skill only.  The patient or care-giver may request the EMS crew to access the iVAD if circumstances dictate.  Accessing the device should be performed when the ambulance is not in motion and preferably prior to departing the scene.  A consult must be performed by all personnel prior to accessing the iVAD unless provider holds advanced (P3 or greater) authorization. Equipment:       Huber Needle Sharpie or indelible marker iVAD prep-kit. 10 cc or 20 cc Syringe IV setup with extension tubing and flushed line. DO NOT uncap distal end of IV tubing until connected to Huber needle tubing. Blood tubes as needed. Revision Date 03/28/2011 499 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix IMPLANTABLE VENOUS ACCESS DEVICE (iVAD) APP 19 Page 500 TOC Indications: For use only in patients that have an iVAD that require medical intervention. This is not a regular and customary vascular access site, when the patient does not require urgent medical therapy. Precautions: Ensure near sterile or most aseptic technique as possible when accessing to minimize the risk of nosocomial infection. Complications:  Flushing of Heparin into patient from iVAD  Mechanical obstruction resolved by having the patient shrug shoulders or lean forward to reduce pressure on subclavian vein.  Embolization of microthrombi. This occurs free flowing IV fluid breaking off microthrombi at the catheter’s distal tip. ALWAYS aspirate at least 10ml of fluid from the catheter prior to flushing with fluid or medication.  Air embolism. Prime all tubing prior to infusion including needle set.  Contamination or infection  Bleeding due to unclamped tubing  Catheter breakage and kinking. Inspect equipment prior to using for damage or visible kinks.  Catheter dislodgement. Procedure: 1. 2. 3. 4. 5. 6. CONSULT as indicated Obtains consent from patient (if not previously obtained) Gather and assemble equipment. Prime IV tubing, huber needle and attached tubing with saline. Exposes skin and palpates VAD Examines site for infection, redness, swelling, pain or other complications. If these exist, DO NOT ACCESS SITE. If the site feels to deep or the site is turned or rotated and you do not feel comfortable accessing it, DO NOT ATTEMPT. 7. Identifies edges of iVAD and center with fingers. 8. Turns patient’s head away from the insertion site. 9. Dons either sterile gloves or a clean set of examination gloves. 10. Cleanse area with Chlorohexidine for a minimum of 90 seconds working from the center out in a circular motion. Repeat this a minimum of 3 times with increasingly larger concentric circles. 11. Allow the site to completely dry. DO NOT blot, blow, or wave a hand past to dry site. These increase the potential for infection. 12. Close clamp on tubing attached to huber needle until ready to aspirate. 13. Stabilize the site with one hand and with the other, insert the needle at a 90o angle through the skin and septum of device. Revision Date 03/28/2011 500 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix IMPLANTABLE VENOUS ACCESS DEVICE (iVAD) APP 19 Page 501 TOC 14. Feel resistance of needle touching the back of the port to avoid subcutaneous placement. 15. Attempt to Aspirate 10 ml of blood to clear heparin and ensure patency of site. WASTE THIS BLOOD. If you are unable to obtain a blood return from the site have the patient raise their arm on the side of the iVAD. If blood return is still not obtained, CONNECT a flushed saline lock and secure site as noted in step 18 and 21. DO NOT FLUSH OR FLOW FLUID THROUGH THE SITE. LEAVE THE NEEDLE IN PLACE AND NOTIFY ER STAFF UPON YOUR ARRIVAL, of the inability to ensure patency of the site by blood return. 16. Aspirates additional blood as needed using vacuutainer luer adapter for laboratory collection tubes. 17. Connect IV tubing and flush with saline solution to clear blood and establish patency of line. 18. Secure needle with sterile dressing. Use folded 4x4’s on either side of needle and cover with tegaderm provided in access kit or clear tape. Treat the device as if it were an impaled object. 19. Observe for signs of infiltration. 20. DO NOT ALLOW IV BAG TO RUN EMPTY. IF AIR ENTERS THE DRIP CHAMBER THIS WILL CAUSE AN AIR EMBOLISM AND CAN KILL THE PATIENT. TO AVOID THIS, CONSIDER THE FOLLOWING     Keep IV Bag vertical at all times. Ensure that IV bag has fluid. Continually monitor flow and ensure that drip chamber is NEVER dry. Do not lay IV bag on patient, between their legs, or in such a position that air can enter the drip chamber. 21. Label edge of tegaderm with the following:  Date accessed  Time accessed  Initials of person accessing 22. Document  Time of access  Patency of site  Site appearance Revision Date 03/28/2011 501 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Controlled Substances APP 20 Page 502 TOC Intent The following policy will define the usage and tracking of all scheduled injectables (controlled medications) within the MCHD System. The goal of the policy is to ensure chain of custody as well as documentation of two (2) MCHD EMS employee signatures that all controlled medications are accounted for at the beginning and end of each shift. The procedures contained in this document constitute guidelines only. The Clinical Department cannot anticipate all extraordinary circumstances that may occur during patient care and the administration of controlled medications. Unusual events should be investigated and addressed on a case by case basis, reviewed by the Assistant Director of Clinical Services and the Medical Director to ensure necessary safeguards are in place to maintain the chain of custody required by Federal and State Rules and Regulations. Failure at any time to maintain the chain of custody for controlled medications as described in these guidelines could result in disciplinary action for all involved MCHD-EMS employees up to and including termination. General Information Ideally the controlled medications should be signed for at the beginning of each shift with the “offgoing” and “on-coming” In-Charge EMT-P’s present. The weekly sign-in sheet should reflect the number of controlled medications counted with documentation of each of the unique numbers assigned or a Controlled Substance Usage and Tracking Form to account for any controlled medications administered during the previous shift that has not been replaced by a Squad medic or Supervisor. The on-coming Paramedic should sign in the “on coming” space as receiving the controlled medications and the Paramedic leaving signs as “off-going” to document transfer of medications. Failure to count and sign for the controlled medications at the beginning of shift may result in disciplinary action for all In-Charge paramedics involved including but not limited to the following: 1st offense 2nd offense 3rd offense 4th offense - written employee action notice 48 hours off 96 hours off termination It is unacceptable for the In Charge paramedic on shift to sign out BEFORE the end of shift (you should not sign in and out at the same time). Failure to comply may result in disciplinary action. Clarification The consensus among the Field Supervisors is that the beginning of the shift is defined by the scheduling software and not by how many continuous hours are being worked. The expectation is that you will sign in/out in the presence of an IC when normal shift changes are being made and when you work more than one assigned shift period you will sign out and back in with the attendant partner. Revision Date 06/21/2012 502 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Controlled Substances APP 20 Page 503 TOC To clarify, if you work a fixed schedule truck such as M32 on Monday night 2300-0700 you will be expected to sign out and back in with your partner at the change of shift at 0700 on Tuesday. The same will be necessary when working 48 hours on the same truck. This will allow for no questionable gaps in tracking/accountability should an audit take place. Although information can be tracked through other processes this is a simple more reliable method. Please contact your local Field Supervisor with questions regarding this information. Additionally When a form is present to track a narcotic that was used you will be required to write the narcotic number with an “F” in front of it. (Example F9999) Simply writing “form” will no longer be acceptable. This will force the employee to scan the form more closely for accuracy and allow for better tracking overall. Late Call and Posting Assignments In the event that a medic unit is assigned an emergency response or post assignment near the end of shift before transfer of the controlled medications can be completed as described above or the oncoming In-Charge EMT-P arrives on the scene of an assigned response and assumes patient care, the following guidelines should be followed. The In-Charge paramedic should complete the sign-in sheet as soon as possible after the call is completed with his/her attendant partner as the witness. Signatures go in the “on coming” signature box to ensure chain of custody and document the Incident number of the late call or the time the post assignment was assigned in the “off Going” signature box on the tracking form. This will indicate to the Clinical Department as well as the Supervisor why the signature is missing and that disciplinary action is unnecessary. Policy violations will remain on file for a six (6) month period and may be considered in a promotional process as a disciplinary violation of Clinical Guidelines as described in Controlled Substances (CG 35) The on-coming In-Charge EMT-P or a designated ICT/ICE candidate is responsible for carrying the key for the controlled medications on his/her person at all times during the shift. When a situation occurs that requires the In-Charge EMT-P to leave work during the shift, the In Charge and the Attendant should count and sign for the controlled medications before the In Charge leaves the station. The In Charge will release custody of the controlled medication keys to the Attendant assigned to the MICU for the remainder of the shift. There may be situations when the In Charge and attendant cannot count before the In Charge leaves (illness/accident requiring transport to a medical facility, etc). In these situations the Attendant should contact his Supervisor and the Supervisor and Attendant should count and sign for the controlled medications. When the replacement In-Charge arrives at the station to complete the shift the In Charge and Attendant should count and sign for the controlled medications to ensure the chain of custody is followed and documented. Peak and Special Event Units MCHD employees assigned to a Peak Unit (In-charge and Attendant) or covering a Special Event (refer to CG 17 in protocols), when a face-to-face exchange of the controlled medications with an off going crew is not practical, the controlled medications should be counted with their partner and Revision Date 06/21/2012 503 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Controlled Substances APP 20 Page 504 TOC both employee signatures should be in the “on coming” space. At the end of shift this process should be repeated as the “off going” crew and the controlled medications should be secured. In situations where it is unclear who should be responsible for the controlled medication key (both crew members are in charge paramedics or the MICU is staffed by attendant paramedics for special events) the employee with the most time at MCHD should be responsible for and carry the controlled medication key. Administration and Replacement of Controlled medications Controlled medications may be administered by MCHD employees who are authorized by protocol in Clinical Guidelines 11 (Medical Authorization Levels). Paramedic Students are allowed to administer controlled medications and other medications under the direction of their Preceptor. After administration of a controlled medication the Paramedic administering the medication should complete appropriate fields of the Controlled Substance Usage and Tracking Form. Supervisors may refuse to replace controlled medications if/when information is missing. Any medications not administered to a patient should be disposed of at the receiving facility. Only MCHD employees should witness the disposal of an unused controlled medication and their name and signature should be documented on the replacement form. If the controlled medication was administered by a student the preceptor should complete the top portion of the replacement form and have his partner witness the waste of controlled medications that were not administered to the patient. The completed usage and tracking form should remain with the controlled medications as it documents why a specific medication is missing and the unique tracking number assigned to the controlled medication should be documented in the PCR. Contact a Supervisor or Squad Medic for replacement. With appropriate documentation, the medic unit may remain in-service with the minimum of one (1) of each controlled medication while awaiting replacement. An MICU should be placed out of service anytime all of one (1) controlled medication has been depleted (i.e. all the Diazepam carried on the unit has been used) and a Supervisor or Squad Medic should be contacted for replacement as soon as possible. PIII’s assigned to a Squad may replace controlled medications to a medic unit after all paperwork has been documented. A Squad may remain in service even though their controlled medication supply is depleted. The completed usage and tracking form should remain with the controlled medications as it documents why a specific medication is missing. They should contact a Supervisor for replacements as soon as possible. Expired Controlled medications All controlled medications should be checked frequently for expiration dates and may be administered through the end of a month (e.g. expires 6/02), unless the expiration date specifies a specific date (e.g. 6/01/02). If possible, medications nearing their expiration date should be administered first in appropriate situations as controlled medications cannot be returned or exchanged. A supervisor should be contacted for replacement before the medication expires. Units/stations with expired controlled medications may result in disciplinary action for all MCHD- Revision Date 06/21/2012 504 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix Controlled Substances APP 20 Page 505 TOC EMS Employees who have been responsible for maintaining the chain of custody for the controlled injectables. Reverse Controlled medication Disposal for Expired Medications and/or Compromised Security Seals To ensure compliance with Federal DEA and State Laws, MCHD will no longer dispose of expired controlled medications at outlying stations/locations when the Tamper Resistant Seal is intact. The procedure for replacing expired controlled medications should be as follows:  Contact your Supervisor and advise them you have controlled medications that are expired/expiring.  The expired controlled medications should be exchanged with the Supervisor with the Tamper Resistant Seal Intact and completed paperwork. The Supervisor will return the expired controlled medications to the Clinical Department for disposal.  Controlled medications that are discovered with broken seals should be exchanged as they are with an unusual occurrence report attached to the Controlled Substance Usage and Tracking Form describing how you found the controlled medication. The replacement form and the compromised controlled medication should be returned to the Clinical Department for disposal. Revision Date 06/21/2012 505 Montgomery County Hospital District-EMS Clinical Guidelines – Appendix PETC INCLUSION/EXCLUSION CRITERIA APP 21 Page 506 TOC Psychiatric Emergency Treatment Center-Tri-County Services Inclusion Criteria: TRUE FALSE INCLUSION CRITERIA – Requires TRUE to all boxes in the INCLUSION Section Patient is capable and willing to admit voluntarily for services. Patient is 18 years or older. Patient DOES NOT have a primary diagnosis of mental retardation, dementia, or substance abuse. Patient IS NOT medically fragile requiring nursing care and monitoring for medical conditions. Patient DOES NOT have a recent or ongoing aggressive or assaultive behavior. Patient is capable of performing all ADL’s (eating, dressing, in/out bed, etc.) independently. Patient reports suicidal/homicidal thoughts with plan OR displays psychotic symptoms of such acuity that they present a danger of harm to self or others. Exclusion Criteria: YES NO EXCLUSION CRITERIA – Requires NO to all boxes in the EXCLUSION Section Decubitus Ulcers Delirium (any signs of confusion) Unstable diabetes, i.e. blood sugar >399 or persons dependent on insulin pumps. Presence or need for ongoing IV therapy, including saline locks. Indwelling tubing, i.e. feeding tubes, Foley cath. Symptoms of active systemic infectious disease, septicemia, sepsis, or requires isolation. Needs for use of oxygen, suctioning, dialysis, telemetry or cardiac monitoring. Need for uninterrupted specialized medical services. Burns requiring daily dressing changes or use of sterile equipment. Wounds requiring medical attention, i.e. sutures. Temperature over 100.4 Blood Pressure > 199 mmHg systolic and/or > 109 diastolic. Symptoms of acute heart failure, unstable angina, or Dyspnea. Any known ingestions medically significant/ Ingestion of dangerous substance (toxins)/ Overdoses (medications) Seizure within the last hour or new onset/uncontrolled seizure episode Use of chemical or physical restraint to prevent harm to self or others Recent history of multiple falls or risk for falls Acute intoxication OR signs of intoxication which limits the ability to give consent. Revision Date 06/21/2012 506 End of Document Revision Date 06/21/2012 507

Clinical Guidelines November 1, 2012 Montgomery County Hospital District Emergency Medical Services

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